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WHO/CDS/IMAI/2004.1 Rev.

Acute Care

INTEGRATED
MANAGEMENT OF
ADOLESCENT AND ADULT
ILLNESS

INTERIM GUIDELINES FOR


FIRST-LEVEL FACILITY HEALTH WORKERS AT
HEALTH CENTRE AND DISTRICT OUTPATIENT CLINIC
October 2005

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This is one of 4 IMAI modules relevant for HIV care:
❖ Acute Care—this module is for adolescents and adults.
For children use the IMCI-HIV adaptation.
❖ Chronic HIV Care with ARV Therapy
❖ General Principles of Good Chronic Care
❖ Palliative Care: Symptom Management and End-of-Life Care
These are interim guidelines released for country adaptation and use to help with the
emergency scale-up of antiretroviral therapy (ART) in resource-limited settings. These interim
guidelines will be revised soon based on early implementation experience. Please send
comments and suggestions to: 3by5help@who.int.
The IMAI guidelines are aimed at first-level facility health workers and lay providers in low-
resource settings. These health workers and lay providers may be working in a health centre
or as part of a clinical team at the district clinic. The clinical guidelines have been simplified
and systematized so that they can be used by nurses, clinical aids and other multi-purpose
health workers, working in good communication with a supervising MD/MO at the district
clinic. Acute Care presents a syndromic approach to the most common adult illnesses
including most opportunistic infections. Instructions are provided so the health worker
knows which patients can be managed at the first-level facility, and which require referral
to the district hospital or further assessment by a more senior clinician. Preparing first-level
facility health workers to treat the common, less-severe opportunistic infections will allow
them to stabilize many clinical stage 3 and 4 patients prior to ARV therapy without referral to
the district.
This module cross-references the IMAI Chronic HIV Care with ART guidelines and Palliative
Care: Symptom Management and End-of-Life Care. If these are not available, national
guidelines for HIV care, ART and palliative care can be substituted.
Integrated Management of Adolescent and Adult Illness (IMAI) is a multi-departmental
project in WHO producing guidelines and training materials for first-level facility health
workers in low-resource settings.

For more information about IMAI, please visit http://www.who.int/hiv/toolkit/arv/


or contact 3by5help@who.int.

WHO HIV Department—IMAI Project

© World Health Organization 2004.


The World health Organization does not warrant that the information contained in this publication is complete and correct, and shall not be
liable for any damages incurred as a result of its use. The mention of specific companies or of certain manufacturers’ products does not imply
that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned.
Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

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Integrated Management: Acute Care

Quick Check
for Emergency
Signs

If laboratory tests are


required, instructions
Assess Acute for these are in the
Illness section, "Laboratory
Tests", pages 111-125.

Classify

Detailed instructions
Identify
are in the section, Treatment
Treatments "Treatment", page 67.

Instructions for advice


Consider HIV- and counselling and Advise
Related Illness HIV testing are in the and
section, "Advise and Counsel
Counsel", page 95.

Prevention:
Screening and
Prophylaxis

Follow-up Care Link with Chronic HIV


for Acute Illness Care.

3
Index
Quick Check for Emergency Signs 10-15
Assess Acute Illness/Classify/Identify Treatments 16
Check in all patients: Respond to volunteered problems or
Ask: cough or difficult observed signs:
breathing? ...............................................16-17 Fever ..........................................................28-30
Check for undernutrition Diarrhoea .................................................32-34
and anaemia ...........................................18-19 Genito-urinary symptoms or lower
Ask: genital or anal sore, abdominal pain in women ................36-39
ulcer or warts? ........................................20-21 Skin problem or lump .........................40-45
Ask men: do you have a Headache or neurological
discharge from your penis? problem ....................................................46-48
Genito-urinary symptoms or Mental problem .....................................50-52
abdominal pain in men ......................22-23 Assess and treat other problems ........... 52
Look in the mouth of all patients and
respond to any complaint of mouth or
dental or throat problem ...................24-26
Ask about pain ............................................. 27
Ask about medications ............................. 27

Consider HIV-related Illness 53


Prevention: Routine Screening and Prophylaxis 57
(for both Acute and Chronic Care patients)
Advise use of insecticide-treated bednet Also for women and girls of
Educate on HIV childbearing age:
Counsel on safer sex Tetanus Toxoid (TT) immunization
Offer HIV testing and counselling If pregnant, link to antenatal care
Offer family planning
Special prevention for adolescents
Counsel to stop smoking
Counsel to reduce or quit alcohol
Exercises, lifting skills to prevent
low-back pain
Do BP screening yearly

Follow-up Care for Acute Illness 61


Urethritis ........................................................ 65
Pneumonia .................................................... 62
Gonorrhea/chlamydia ............................... 65
TB sputums ................................................... 63
Candida vaginitis ........................................ 65
Fever ............................................................... 63
Bladder infection ........................................ 66
Persistent diarrhoea .................................. 64
Menstrual problem .................................... 66
Oral or oesophageal candida ................. 64
PID .................................................................... 66
Anogenital ulcer .......................................... 64
BV or trichomonas vaginitis .................... 66
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Treatment 67
IV/IM drugs:
benzathine PCN ........................................... 69 See IMAI Quick Check and Emergency
glucose ........................................................... 69 Treatments module for instructions on:
IM antimalarial ............................................. 70 Manage airway
diazepam IV or rectally ............................. 71 Insert IV, rapid fluids
IV/IM antibiotics .......................................... 72 Insert IV, slow fluids
Metered dose inhaler: Recovery position
salbutamol..................................................... 74 Classify/treat wheezing/use epinephrine

Oral drugs
Oral antibiotics............................................. 76 aciclovir .......................................................... 85
GC/chlamydia antibiotics ......................... 78 fluconazole .................................................... 85
metronidazole .............................................. 79 ketoconazole ................................................ 85
Oral antimalarial .......................................... 80 podophyllin................................................... 85
paracetamol .................................................. 80 Treat scabies ................................................. 86
albendazole/mebendazole ..................... 81 Symptom control for cough/cold/
prednisolone ................................................ 81 bronchitis ....................................................... 87
amitriptyline ................................................. 82 iron/folate ...................................................... 87
haloperidol .................................................... 83 Fluid plans A/B/C for diarrhoea .......88-91
nystatin ........................................................... 84 Refer urgently to hospital ..................92-93
Antiseptic ....................................................... 84

Advise and Counsel 95


Provide key information on HIV............97
HIV testing and counselling .............98-99
Pre-test information .......................100-101 Use brief intervention
Advantages of knowing HIV status .. 102 guidelines for:
Post-test counselling .....................103-104 Tobacco use
Counsel on safer sex .............................. 105 Hazardous alcohol use
Educate/counsel on STIs ...................... 106 Physical inactivity
Basic counselling.............................107-108 Poor diet
Counsel the depressed patient
and family ..........................................109-110

Laboratory Tests 111


(Some may be available only at health centre or
district level.)

Collect sputums for TB .......................... 112 Insert instructions for other lab tests
Register of TB suspects ......................... 114 which can be performed in clinic:
Send sputum samples to Haemoglobin
laboratory .................................................. 116 Urine dipstick for sugar or protein
Malaria smear (thick film) ..................... 117 Blood sugar by dipstick
RPR (syphilis) testing......................118-119 Malaria dipstick
Rapid test for HIV ............................120-125

Recording Form/Desk Aid 126-129


5
Steps to Use the IMAI Acute
Care Module
Quick Check Do the Quick Check for Emergency Signs—if any
for Emergency positive sign, call for help and begin providing
Signs the emergency treatment.

Ask: What is your problem? Why did you come for


Assess Acute
this consultation? Prompt: "Any other problems?"
Illness

• Determine if patient has acute illness or is here for follow-up. Circle this
on the recording form (126).
• How old are you?
• If woman of childbearing age, are you pregnant? (She will also need
to be managed using the antenatal guidelines—circle this on the
recording form.)
In all patients:
• Ask: cough or difficult breathing? (16-17)
• Check for undernutrition and anaemia. (18-19)
• Ask: genital or anal sore, ulcer or warts? (20-21)
• Ask men: do you have a discharge from your penis? (22-23)
• Look in the mouth (and respond to volunteered
mouth/dental/throat problems). (24-26)
• Ask about pain. (27)

If patient is in pain, grade the pain, determine location and consider


cause. Manage pain using the Palliative Care module.
• Ask: Are you taking any medications?

Respond to volunteered problems or observed signs.

Mark with an X on the recording form all the main symptoms


the patient has.

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You will need to do the assessment for any of these symptoms if
volunteered or observed:
• Fever (28-30)
• Diarrhoea (32-34)
• Genito-urinary symptoms or lower abdominal pain in women (36-39)
• Skin problem or lump (40-45)
• Headache or neurological problem or painful feet (46-48)
• Mental problem (50-52)—use this page if patient complains of or appears
depressed, anxious, sad or fatigued, or has an alcohol problem, recurrent
multiple complaints or pain. Remember to use this page. If you have
a doubt, use it.
For special considerations in assessing adolescents,
see Adolescent Job Aid.

Assess and treat other problems. Use national and other existing
guidelines for other problems that are not included in the Acute Care
module.

If laboratory tests are required, instructions for these are in the section
"Laboratory Tests" at the end of the module (111).

Classify using the IMAI acute care algorithm,


Classify following the 3 rules:

1. Use all classification tables where the patient fits the


description in the arrow.
2. Start at the top of the classification table. Decide if the patient’s signs fit
the signs in the first column. If not, go down to next row.
3. Once you find a row/classification—STOP! Use only one row in each
classification table. (Once you find the row where the signs match, do not
go down any further, even if the patient has signs that also fit into other,
lower rows/classifications.)

Then record all classifications on the recording form. Remember that there
is often more than one.

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Read the treatments for each classification you have
Identify
chosen. List these.
Treatments

The detailed treatment instructions are in the section Treatment


called Treatment.

Instructions for patient education, support and Advise


counselling are in Advise and Counsel, including how and
to suggest HIV testing and counselling. Counsel

If it advises you to "Consider HIV-related illness", circle


Consider HIV-
this on the recording form and use this section.
Related Illness

If the patient is HIV+, also use the Chronic HIV Care module, for chronic
care, ART, prevention and support.

If the treatment list advises sputums for TB, note this on the recording
form and send sputums.

Prevention: Remember that for all patients you need to also


Screening and consider what Prevention and Prophylaxis are
Prophylaxis required. (Circle on the recording form.)

Follow-up Care Reassess the patient and treat or refer as necessary.


for Acute Illness This is initial follow-up care after acute illness, not
ongoing chronic care.

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Quick Check for
Emergency Care
then

Assess Acute Illness/


Classify/Identify
Treatments

9
Quick Check for
Emergency Signs

Use this chart for rapid triage assessment for all patients. Then use the
Acute Care guidelines.
If trauma or violent or aggressive patient, or other psychiatric
emergency, also see the Quick Check module.
Quick check for emergency signs (medical)
(Consider all signs)

FIRST ASSESS: AIRWAY AND BREATHING

• Appears obstructed or
• Central cyanosis (blue Check for obstruction,
mucosa) or wheezing and pulmonary
oedema.
• Severe respiratory
distress

THEN ASSESS: CIRCULATION (SHOCK)

• Cold skin or
• Weak and fast pulse or Check BP and pulse. Look for
bleeding. Ask: Have you had
• Capillary refill longer diarrhoea?
than 2 seconds

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TREATMENT

• If obstructed breathing, manage the airway.


• Prop patient up or help to assume position for
best breathing.
• If wheezing, treat urgently (p. 74).
• If pulmonary oedema, consider furosemide if
known heart disease.
• Give appropriate IV/IM antibiotics pre-referral.
• Refer urgently to hospital.
If trauma—see
Quick Check
module.
This patient may be in shock:
• If systolic BP < 90 mmHg or pulse >110 per
minute:
— Insert IV and give fluids rapidly.
If not able to insert peripheral IV,
use alternative.
— Position with legs higher than chest.
— Keep warm (cover).
— Consider sepsis—give appropriate IV/IM
antibiotics.
— Refer urgently to hospital.
• If diarrhoea: assess for dehydration and follow
plan C. (This patient may not need referral after
rehydration.) If severe undernutrition, see p. 18.
• If melena or vomiting blood, manage as in
Quick Check module and refer to hospital.
• If haemoptysis > 50 ml, insert IV and refer to
hospital.

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UNCONSCIOUS/CONVULSING

• Convulsing (now or
recently), or
• Unconscious. Measure BP and
If unconscious, ask temperature
relative: Has there been
a recent convulsion?

PAIN

If chest pain: Check BP, pulse,


• What type of pain? temperature and age

If severe abdominal pain: Check BP, pulse


• Is abdomen hard? and temperature

If neck pain or severe


headache: Check BP
Ask patient to move neck—do
• Has there been any not passively move
trauma?

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For all:
• Protect from fall or injury. Get help.
• Assist into recovery position. (Wait until
convulsion ends.)
• Insert IV and give fluids slowly. If trauma,
• Give appropriate IM/IV antibiotics. use the
• Give IM antimalarial. Quick Check
• Give glucose *. guidelines.
• Refer urgently to hospital after giving pre-referral
care. Do not leave alone.
If convulsing, also:
• Give diazepam IV or rectally.
• Continue diazepam en route as needed.
If unconscious:
• Manage the airway.
• Assess possibility of poisoning, alcohol or
substance abuse.

If age > 50, no history of trauma and history


suggests cardiac ischaemia:
• Give aspirin (160 or 325 mg, chewed).
• Refer urgently to hospital.
For other pain,
If pleuritic pain with cough or difficult breathing,
use the Acute
assess for pneumonia. Consider pneumothorax.
Care module
to determine
cause.
• Insert IV. If hard abdomen or shock, give fluids
rapidly. If not, give fluids slowly (30 drops/minute). See the
• Refer urgently to hospital *. Palliative Care
module for
management
of pain.
• Consider meningitis and other causes of acute
headache. (See p. 46-48.)
• If BP > systolic 180, refer urgently to hospital.
• If pain on neck movement by patient after trauma * If high glucose, see
by history or exam, immobilize the neck and refer. diabetes management
guidelines.

13
FEVER from LIFE-THREATENING CAUSE

• Any fever with:


— stiff neck
— very weak/not able
to stand
— lethargy Any sign present—measure
temperature and BP.
— unconscious
— convulsions
— severe abdominal
pain
— respiratory distress

14
• Insert IV. Give fluids rapidly if shock or
suspected sepsis. If not, give fluids slowly (30
drops/minute). Also consider
neglected
• Give appropriate IV/IM antibiotics. trauma with
• Give appropriate IM antimalarial. infection—see
• Give glucose. Quick Check
guidelines.
• Refer urgently to hospital.

If no emergency signs, proceed immediately to

Assess Acute Illness/


Classify/Identify
Treatments
Ask: what is your problem? Why did you come for this consultation?
Prompt: "Any other problems?"
• Determine if patient has acute illness or is here for follow-up. Circle this
on recording form (p. 126).
• How old are you?
• If woman of childbearing age, are you pregnant? (She will also need to
be managed using the antenatal guidelines—circle this on the recording
form.)

15
Assess Acute Illness

In all patients: Do you have cough or difficult breathing?

IF YES, ASK: LOOK AND LISTEN Classify


in all
with
• For how long? • Is the patient lethargic?
cough:
• Are you having chest pain? • Count the breaths in one
— If yes, is it new? Severe? minute—repeat if elevated.
Describe it. • Look and listen for
• Have you had night sweats? wheezing.
• Do you smoke? • Determine if the patient is
• Are you on treatment for uncomfortable lying down.
a chronic lung or heart • Measure temperature.
problem, or TB? Determine
if patient diagnosed as If not able to walk unaided or
asthma, emphysema or appears ill, also:
chronic bronchitis (COPD),
• Count the pulse.
heart failure or TB. (Also look
in Chronic Disease Register.) • Measure BP.
• If not, have you had
previous episodes of cough
or difficult breathing?
— If recurrent:
–– Do these episodes
of cough or difficult
breathing wake you
up at night or in the
early morning?
–– Do these episodes
occur with exercise?

AGE FAST BREATHING IS: VERY FAST BREATHING IS:


5-12 years 30 breaths per minute or more 40 breaths per minute
13 years or 20 breaths per minute or more 30 breaths per minute or more
more

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Use this classification table in all with cough or difficult breathing:

SIGNS: CLASSIFY AS: TREATMENTS:


One or more of the SEVERE PNEUMONIA • Position.
following signs: OR VERY SEVERE • Give oxygen.
• Very fast breathing or DISEASE • Give first dose IM antibiotics.
• High fever (39°C or above) or • If wheezing present, treat (p. 74).
• Pulse 120 or more or • If severe chest pain in patient 50
• Lethargy or years or older, use Quick Check.
• Not able to walk unaided or • If known heart disease and
uncomfortable lying down, give
• Uncomfortable lying down or furosemide.
• Severe chest pain. • Refer urgently to hospital.
• Consider HIV-related illness
(p. 54).
• If on ARV therapy, this could be a
serious drug reaction. See Chronic
HIV Care module.
Two of the following signs: PNEUMONIA Give appropriate oral antibiotic
• Fast breathing Exception: if second/third trimester
• Night sweats pregnancy, HIV clinical stage 4, or
low CD4 count, give first dose IM
• Chest pain antibiotics and refer urgently to
hospital.
• If wheezing present, treat (p. 74).
• If smoking, counsel to stop smoking.
• Consider HIV-related illness (p. 54).
• If on ARV therapy, this could be a
serious drug reaction; consult/refer.
• If cough > 2 weeks, send sputums
for TB (p. 63).
• Advise when to return immediately.
• Follow up in 2 days (p. 62).
• Cough or difficult breathing POSSIBLE CHRONIC • If cough > 2 weeks, send 3 sputums
for more than 2 weeks or LUNG OR HEART for TB or send the patient to district
• Recurrent episodes of cough hospital for sputum testing. (Record
PROBLEM in register.)
or difficult breathing which:
- Wake patient at night or in • If sputums sent recently, check
the early morning or register for result. If negative, refer to
- Occur with exercise. district hospital for assessment if a
chronic lung problem has not been
diagnosed (p. 63).
• If smoking, counsel to stop.
• If wheezing, treat (p. 74).
• Advise when to return immediately.
• Insufficient signs for the NO PNEUMONIA • Advise on symptom control.
above classifications COUGH/COLD, OR • If smoking, counsel to stop.
BRONCHITIS • If wheezing, treat (p. 74).
• Advise when to return immediately.

17
Check all patients for undernutrition
and anaemia:

IF YES, ASK: LOOK AND FEEL If visible


wasting
or weight
• Have you lost weight? • Look for visible wasting. loss:
• What medications are • Look for loose clothing.
you taking?
If present, did it fit before?
If wasted or reported If wasted or reported
weight loss, how much has weight loss:
your weight changed? • Weigh and calculate
% weight loss.
• Ask about diet.
• Measure mid-upper arm
• Ask about alcohol use. circumference (MUAC).
• Look for sunken eyes.
% weight loss = • Look for oedema of the
old–new legs.
old weight If present:
• Does it go up to the
knees?
• Is it pitting?
• Assess for infection
If pallor: using the full Acute Care If pallor:
• Black stools? algorithm.
• Blood in stools? • Look at the palms and
• Blood in urine? conjunctiva for pallor.
• In menstruating Severe?
adolescents and women: Some?
heavy menstrual periods? If pallor: *
• Count breaths in one
minute.
• Breathless?
• Bleeding gums?
• Petechiae?

* If haemoglobin result available, classify as SEVERE ANAEMIA


if haemoglobin < 7 gm; SOME ANAEMIA if < than 10 gm.

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Use this table if visible wasting or weight loss:
SIGNS: CLASSIFY AS: TREATMENTS:
• MUAC < 160 mm or SEVERE UNDER- • Refer for therapeutic feeding if nearby
• MUAC 161-185 mm plus one NUTRITION or begin community-based feeding.
of the following: • Consider TB (send sputums if possible).
- Pitting edema to knees on • Consider HIV-related illness (p. 54).
both sides • Counsel on HIV testing.
- Cannot stand
- Sunken eyes
• Weight loss > 5 % or SIGNIFICANT • Treat any apparent infection.
• Reported weight loss or WEIGHT LOSS • If diarrhoea, manage as p. 32-34.
• Loose clothing which used • Increase intake of energy and nutrient-
to fit. rich food—counsel on nutrition.
• Consider TB (send sputums if possible);
diabetes mellitus (dipstick urine for
glucose); excess alcohol; and substance
abuse.
• Consider diabetes mellitus if weight loss
accompanied by polyuria or increased
thirst (dipstick urine for glucose).
• Consider HIV-related illness (p. 54).
• Counsel on HIV testing.
• Follow up in two weeks.
* Weight loss < 5 %. NO SIGNIFICANT • Advise on nutrition.
WEIGHT LOSS

Use this table if pallor


• Severe palmar and SEVERE ANAEMIA • Refer to hospital.
conjunctival pallor; OR OTHER SEVERE • If not able to refer, treat as below and
• Any pallor with: PROBLEM follow up in one week.
- 30 or more breaths per • Consider HIV-related illness (p. 54).
minute or
• Consider ARV side effect (especially
- Breathless at rest;
ZDV) or cotrimoxazole side effects.
• Bleeding gums or petechiae; or
(See Chronic HIV Care.)
• Black stools or blood in stools.
• Consider malaria if low immunity
or increased exposure (p. 28).
• Palmar or conjunctival pallor. SOME ANAEMIA • Consider HIV-related illness (p. 54).
• ARV drugs, especially ZDV and
cotrimoxazole, can cause anaemia.
(See Chronic HIV Care.)
• Consider malaria if low immunity
or increased exposure (p. 28).
• Give twice daily iron/folate.
• Counsel on adherence.
• Advise to eat locally available foods
rich in iron.
• Give albendazole if none in last
6 months.
• If heavy menstrual periods—see p. 39.
• Follow up in 1 month.

19
In all patients, ask: Do you have a genital or anal sore,
ulcer or wart?

If anogenital
IF YES, ASK: LOOK AND FEEL ulcer:

• Are these new? • Look for anogenital


If not, how often have sores or ulcers.
you had them? • Look for vesicles.
• Look for warts.
• Look/feel for enlarged
lymph node in inguinal
area.
If present: Is it painful?

* For haemorrhoids/anal fissure


management, see Palliative Care.

If painful
inguinal node:

If warts:

20
SIGNS: CLASSIFY AS: TREATMENTS:
• Only vesicles GENITAL HERPES • Keep clean and dry.
present • Give aciclovir, if available.
• Promote/provide condoms.
• Educate on STIs, HIV and risk reduction. Offer
HIV testing, counselling and syphilis testing.
• Sore or ulcer GENITAL ULCER • Give benzathine penicillin for syphilis.
• Give ciprofloxacin for chancroid.
• If vesicles also give aciclovir if available.
• Promote/provide condoms.
• Consider HIV infection. Offer HIV testing and
counselling.
• Consider HIV-related illness if ulcerations
present > one month (p. 54).
• Educate on STIs, HIV and risk reduction.
• Treat all partners within last 3 months.
• Follow up in 7 days if sores not fully healed,
and earlier if worse (p. 64).

• Enlarged INGUINAL BUBO • If ulcer also present give ciprofloxacin


and painful for 3 days.
inguinal • If no ulcer give doxycycline for 21 days;
node also treat partner.
• If fluctuant, aspirate through healthy skin;
do not incise.
• Promote/provide condoms.
• Partner management.
• Consider HIV infection. Offer HIV testing and
counselling and syphilis testing.
• Educate on STIs, HIV and risk reduction.
• Follow up in 7 days (p. 64).

• Warts GENITAL WARTS • Apply podophyllin.


• Consider HIV-related illness.
• Offer HIV testing and counselling.
• Educate on STIs, HIV and risk reduction.

21
Ask men: Do you have a discharge from your penis?
If male patient complains of genito-urinary
symptoms or lower-abdominal pain:
(Use this page for men.)
If lower-abdominal
IF YES, ASK: LOOK AND FEEL pain:

• What is your problem? Perform genital exam:


• Do you have discharge • Look for scrotal
from your urethra? swelling.
— If yes, for how long? • Feel for tenderness.
If this is a persistent • Look for ulcer:
or recurrent problem, — If present, also use
see follow-up box. p. 20.
• Do you have burning or • Look for urethral
pain on urination? discharge.
• Do you have pain in • Look and feel for If urethral discharge
your scrotum? rotated or elevated or
testis. urination problems:
— If yes, have you had
any trauma there? — If abdominal pain, feel
• Do you have sore(s)? for tenderness.
— If tenderness:
–– Is there rebound?
–– Is there guarding?
–– Can you feel a
mass?
–– Are bowel sounds
present?
–– Measure If scrotal swelling
or tenderness:
temperature.
–– Measure pulse.

* If fever with right lower abdominal pain and referral is delayed, give
ampicillin and metronidazole for possible appendicitis.

22
Use this table in men with lower abdominal pain:

SIGNS: CLASSIFY AS: TREATMENTS:


Abdominal tenderness with: SEVERE OR SURGICAL • Give patient nothing by
• Fever > 38°C or ABDOMINAL mouth (NPO).
• Rebound or PROBLEM • Insert IV.
• Guarding or • Give appropriate IV/IM
• Mass or antibiotics.
• Absent bowel sounds or • Refer URGENTLY to
• Not able to drink or hospital.*
• Pulse > 110
• Abdomen soft and none GASTROENTERITIS OR • If diarrhoea, see p. 32.
of the above signs OTHER GI PROBLEM • If constipation, advise
remedies.
• Return if not improved.

Use this table in men with urethral discharge or urination problem


• Not able to urinate and PROSTATIC • Pass urinary catheter if
• Bladder distended OBSTRUCTION trained.
• Refer to hospital.
• Urethral discharge or POSSIBLE • Treat patient and partner
• Burning on urination GONORRHOEA/ with antibiotics for possible
GC/chlamydia infection.
CHLAMYDIA
• Promote/provide condoms.
INFECTION
• Return if worse or not
improved within 1 week
(p. 65).
• Offer HIV/STI counselling
and HIV and syphilis testing.
• Consider HIV infection
(p. 54).
• Partner management.

Use this table in all men with scrotal swelling or tenderness


• Testis rotated or elevated POSSIBLE TORSION • Refer URGENTLY to
or hospital for surgical
• History of trauma evaluation.
• Swelling or tenderness POSSIBLE • Treat patient and partner
(without the above signs) GONORRHOEA/ with antibiotics for possible
GC/chlamydia infection.
CHLAMYDIA
• Promote/provide condoms.
INFECTION
• Follow up in 7 days; return
earlier if worse (p. 65).
• Offer HIV counselling and
HIV and syphilis testing.
• Consider HIV infection
(p. 54).

23
Look in the mouth of all patients and respond to any
complaint of mouth or throat problem:
If you see any If patient
abnormality or patient LOOK has white
complains of a mouth or or red
throat problem, ASK: patches:

• Do you have pain? Look in mouth for:


— If yes, where? • White patches
When does this — If yes, can they be
occur? (When removed?
swallowing? • Ulcer Classify
When hot or - If yes, are they
cold food?) deep or extensive?
• Do you have • Tooth cavities
problems
• Loss of tooth
swallowing?
substance
• Do you have
• Bleeding from gums
problems chewing?
• Swelling of gums If sore
• Are you able to eat?
• Gum bubble throat,
• What medications are
• Pus without
you taking? mouth
• Dark lumps problem:
Look at throat for:
• White exudate
• Abscess
Look for swelling over
jaw.
Feel for enlarged lymph If mouth
nodes in neck. ulcer
or gum
If patient complains problem,
p. 22.
of tooth pain, does
tapping or moving the If tooth
tooth cause pain? problem
or jaw
pain or
swelling,
p. 22.

24
If patient has white or red patches:
SIGNS: CLASSIFY AS: TREATMENTS:
• Not able to swallow SEVERE OESOPHAGEAL • Refer to hospital.
THRUSH • If not able to refer, give
fluconazole.
• Pain or difficulty OESOPHAGEAL THRUSH • Give fluconazole.
swallowing • Give oral care.
• Follow up in 2 days (p. 64).
• Consider HIV-related
illness (p. 54).
• White patches in ORAL THRUSH • Give nystatin or
mouth and miconazole gum patch
• Can be scraped off or clotrimazole.
• If extensive, give
fluconazole or
ketoconazole.
• Give oral care.
• Consider HIV-related
illness (p. 54).
• White patches/vertical ORAL (HAIRY) • No treatment needed.
ridges on side of LEUKOPLAKIA • Consider HIV-related
tongue and illness (p. 54).
• Cannot be • Instruct in oral care.
scraped off and
• Painless.
Use this table if sore throat without mouth problem:
• Not able to swallow or TONSILLITIS • Refer urgently to
• Abscess. hospital.
• Give benzathine
penicillin.
• Enlarged lymph node STREPTOCOCCAL SORE • Give benzathine
on neck and THROAT penicillin.
• White exudate on • Soothe throat with a
throat. safe remedy.
• Give paracetamol for
pain.
• Return if not better.
• Only 1 or no signs in NON-STREP SORE • Soothe throat with a
the above row present. THROAT safe remedy.
• Give paracetamol
for pain.

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25
Use this table if mouth ulcer or gum problem:

SIGNS: CLASSIFY AS: TREATMENTS:


• Deep or extensive SEVERE GUM/ • Refer urgently to hospital unless only
ulcers of mouth or MOUTH INFECTION palliative care planned.
gums or • Trial aciclovir.
• Not able to eat • Start metronidazole if referral not
possible or distant.
• Consider HIV-related illness (p. 54).
• If on ARV therapy, this may be drug
reaction. (See Chronic HIV Care.)
• Ulcers of mouth or GUM/MOUTH • Show patient/family how to clean with
gums. ULCERS saline, peroxide or sodium bicarbonate.
• If lips or anterior gums, give aciclovir.
• Instruct in oral care.
• Consider HIV-related illness (p. 54).
• If on ARV, started cotrimoxazole or INH
prophylaxis within last month, this may
be drug reaction, especially if patient
also has new skin rash. (See Chronic HIV
Care—refer, stop drugs.)
• See Palliative Care for pain relief.
• Follow up in 7 days.
• Bleeding from GUM DISEASE • Instruct in oral care.
gums (in absence
of other bleeding or
other symptoms)
• Swollen gums

Use this table if tooth problem, jaw pain or swelling:


• Constant pain with: DENTAL ABSCESS • If fever, give antibiotics.
- Swollen face or • Lance abscess or pull tooth.
gum near tooth
or • Refer urgently to dental assistant
- Gum bubble or if not able to do so.
• Consider sinusitis. (Do not pull teeth
• Tooth pain when if this is cause.)
tapped or moved.
• Pain when eating TOOTH DECAY • Place gauze with oil of clove.
hot or cold food or • Refer to dentist for care or pull tooth.
• Visible tooth
cavities or
• Loss of tooth
substance.

26
In all patients, ask: Are you in pain?
• If patient is in pain, grade the pain, determine location and consider
cause.
• Manage pain using the Palliative Care guidelines.

In all patients, ask: Are you taking any medications?


It is particularly important to consider toxicity from ARV drugs and
immune reconstruction syndrome in the first 2-3 months of antiretroviral
therapy (ART), when evaluating new signs and symptoms.

Now respond to:

Volunteered Problems
or Observed Signs

27
Does the patient have fever—by history of recent fever
(within 48 hours) or feels hot or temperature 37.5°C or above?

IF YES, ASK: LOOK AND FEEL


Patient
has high
• How long have you had a • Look at the patient’s malaria
fever? neurological condition. Is the risk
• Any other problem? patient:
— Lethargic? Confused?
• What medications have you Agitated?
taken?
• Count the breaths in one
Determine if antimalarial and for minute. Use table on p.16 to
how long. determine if fast breathing.
Decide malaria risk: — If fast breathing , is it deep?
High Low No • Check if able to drink.
• Where do you usually live? • Feel for stiff neck.
• Have you recently travelled to • Check if able to walk unaided.
a malaria area? • Skin rash?
• If woman of childbearing age:
• Headache? For how long?
- Are you pregnant?
• Is an epidemic of malaria • Look for apparent cause of
occurring? fever. (Assess all symptoms in
this Acute Care algorithm and
• HIV clinical stage 3 or 4. consider whether this could be
related to ARV treatment—see
Classify the individual Chronic HIV Care.)
patient’s malaria risk: • Do malaria dipstick or smear if
available.
Patient
has low
If low immunity (with malaria transmission): malaria
• Pregnant.
• Child < 10 years, if there is intense or moderate malaria.
risk
HIGH
MALARIA • Stage 3 or 4 HIV infection. (See Chronic HIV Care module.)
RISK Or increased exposure:
• Epidemic of malaria is occurring.
• Moved to or visited area with intense or moderate malaria.

If high immunity:
• Adolescent or adult who has lived since childhood
LOW in area with intense or moderate malaria.
MALARIA Or low exposure:
RISK
• Low malaria transmission and no travel to higher
transmission area.
Patient
NO has no
MALARIA • If no malaria transmission and
RISK • No travel to area with malaria transmission. malaria
risk, p. 30
28
Use this table if patient has fever with high malaria risk:
SIGNS: CLASSIFY: TREATMENTS:
One or more of the following VERY SEVERE • Give IM quinine or artemether.
signs: FEBRILE • Give first dose IM antibiotics.
• Confusion, agitation, DISEASE • Give glucose.
lethargy or • Refer urgently to hospital.
• Fast and deep breathing or
• Not able to walk unaided or
• Not able to drink or
• Stiff neck
• Fever or history of fever MALARIA • Give appropriate oral antimalarial.
• Determine whether adequate treatment
already given with the first-line antimalarial
within 1 week—if yes, an effective second-
line antimalarial is required.
• Look for other apparent cause.
• Consider HIV-related illness (p. 54).
• If fever for 7 days or more, consider TB.
(Send sputums/refer.)
• Follow up in 3 days if still febrile (p. 63).

Use this table if patient has fever with low malaria risk:
• Confusion, agitation, VERY SEVERE • Give IM quinine or artemether.
lethargy or FEBRILE • Give first dose IM antibiotics.
• Not able to drink or DISEASE • Give glucose.
• Not able to walk unaided or • Refer urgently to hospital.
• Stiff neck or
• Severe respiratory distress
• Fever or history of fever and MALARIA • Give appropriate oral antimalarial.
• No new rash and • Determine whether adequate treatment
• No other apparent cause of already given with the first-line
fever or antimalarial within 1 week—if yes, an
• Dipstick or smear positive for effective second-line antimalarial is
malaria required.
• Consider fever related to ARV use.
(See Chronic HIV Care.)
• Follow up in 3 days if still febrile (p. 63).
• Other apparent cause of FEVER • Treat according to the apparent cause.
fever or MALARIA (Exception: Also give IM antimalarial
• New rash or UNLIKELY if patient is classified as SEVERE
• Dipstick or smear negative PNEUMONIA.)
for malaria • Consider HIV related illness if unexplained
fever for > 30 days (p. 54).
• Consider fever related to ARV use.
(See Chronic HIV Care.)
• If no apparent cause and fever for 7 days
or more, send sputums for TB and refer
to hospital for assessment (p. 63).

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29
Use this table if patient has fever with no malaria risk:

SIGNS: CLASSIFY AS: TREATMENTS:


• Confusion, agitation, VERY SEVERE FEBRILE • Give first dose IM
lethargy or DISEASE antibiotics.
• Not able to drink or • Give glucose.
• Not able to walk • Refer urgently to
unaided or hospital.
• Stiff neck
• Fever for 7 days PERSISTENT FEVER • Treat according to
or more apparent cause.
• Consider TB. (Send
sputums/refer.)
• If no apparent cause,
refer to hospital for
assessment.
• Consider HIV related
illness if unexplained
fever for > 7 days
(p. 54).
• Consider fever related
to ARV use. (See
Chronic HIV Care.)
• None of the above SIMPLE FEVER • Follow up in 2-3 days
if fever persists (p. 63).
• Treat according to
apparent cause.

30
NOTES:

31
If the patient has diarrhoea:

IF YES, ASK: LOOK AND FEEL


Classify all
• For how long? • Is the patient patients with
lethargic or diarrhoea for
– If more than DEHYDRATION:
14 days, have unconscious?
you been • Look for sunken eyes.
treated before • Is the patient:
for persistent – Not able to drink or
diarrhoea? drinking poorly? Classify
– If yes, with what? – Drinking eagerly, DIARRHOEA
When? thirsty?
• Is there blood in the • Pinch the skin of the
stool? inside of the forearm.
Does it go back:
– Very slowly (longer
than 2 seconds)?
– Slowly?

If diarrhoea
for 14 days
or more and
no blood,
p. 34.

And if blood
in stool,
p. 34.

32
Use this table in all patients with diarrhoea:

SIGNS: CLASSIFY AS: TREATMENTS:


Two of the following signs: SEVERE • If no other severe
classification, give fluid
• Lethargic or unconscious DEHYDRATION for severe dehydration,
• Sunken eyes (Plan C on p. 90) then
• Not able to drink or reassess. (This patient
drinking poorly may not require referral.)

• Skin pinch goes back very Or, if another severe


slowly classification:
• Refer URGENTLY to
hospital after initial
IV hydration or, if not
possible, with frequent
sips of ORS on the way.
If there is cholera in your
area, give appropriate
antibiotic for cholera
(according to sensitivity
data).
Two of the following signs: SOME • Give fluid and food for
some dehydration. (See
• Sunken eyes DEHYDRATION Plan B on p. 89.)
• Drinks eagerly, thirsty
• Advise when to return
• Skin pinch goes back immediately.
slowly
• Follow up in 5 days if not
improving.
Not enough signs to NO • Give fluid and food to
classify as some or severe treat diarrhoea at home.
dehydration
DEHYDRATION (See Plan A on p. 88.)
• Advise when to return
immediately.
• Follow up in 5 days if not
improving.

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33
Also use this table if diarrhoea for 14 days or more and no blood:

SIGNS: CLASSIFY AS: TREATMENTS:


• Some or severe SEVERE PERSISTENT • Give fluids for
dehydration present DIARRHOEA dehydration (Plan B
or C on pp. 89-90) before
referral, then reassess.
(This patient may not
require referral.)
• If signs of dehydration
persist, or another severe
classification, refer
urgently to hospital.
• No dehydration PERSISTENT • Give appropriate
DIARRHOEA empirical treatment,
depending on recent
treatment and HIV status.
• Consider HIV-related
illness (p. 54).
• If on ARV treatment, this
could be drug side effect.
(See Chronic HIV Care.)
• Give supportive care for
persistent diarrhoea. (See
Palliative Care.)
• Give nutritional advice
and support.
• Follow up in 5 days.
(Explain when to refer.)

Also use this table if blood in stool:


• Blood in the stool DYSENTERY • Treat for 5 days with
an oral antibiotic
recommended for
Shigella in your area.
• Advise when to return
immediately.
• Follow up in 2 days.

34
NOTES:

35
If female patient complains of genito-urinary
symptoms or lower abdominal pain:
❖ For an adult non-pregnant woman or an adolescent, use this page.
❖ For a pregnant woman, use antenatal guidelines.
❖ For a man, use page 22.
If lower
abdominal
IF YES, ASK: LOOK AND FEEL pain (other
than menstrual
• What is the problem? • Feel for abdominal cramps):
• What medications are you tenderness.
taking? If tenderness:
Do you have: — Is there rebound?
• Burning or pain on urination? — Is there guarding?
• Increased frequency of — Can you feel a mass?
urination? — Are bowel sounds Classify:
• Ulcers or sore in your genital present?
area? — Measure temperature.
• An abnormal vaginal — Measure pulse.
discharge? If abnormal
— If yes, does it itch? • Perform external exam, look vaginal discharge,
• Any bleeding on sexual for large amount of vaginal p. 38.
contact? discharge. (If only small
amount white discharge in Burning or pain on
• Has your partner had any urination or flank
genital problem? adolescent, this is usually
normal.) pain, p. 38.
— If partner is present,
ask him about urethral If menstrual pain or
discharge or sores. • Look for anal or genital ulcer.
missed period
• When was your last menstrual If present, also use p. 20. or bleeding
period? irregular or very
— If missed period: Do • Feel for enlarged inguinal
lymph node. heavy periods,
you think you might be p. 39.
pregnant? If present, also use p. 20.
Have you had very heavy or
irregular periods? • If you are able to do
— If yes: bimanual exam, feel for
–– Is the problem new? cervical motion tenderness.
–– How many days does • If burning or pain on If suspect
your bleeding last? urination or complaining gonorrhoea/
–– How often do you for back or flank pain: chlamydia
change pads or infection based
tampons? — Percuss flank for
tenderness. on any of these
• Do you have very painful factors:
menstrual cramps?
• Are you using contraception?
If yes, which one?
• Are you interested in
contraception? If yes, use
Family Planning guidelines**.
* If fever with right lower abdominal pain and referral is delayed, give ampicillin and metronidazole for possible appendicitis.
** Such as Decision-Making Tool for Family Planning Clients and Providers.
36
Use this table in all women with lower abdominal pain (other than
menstrual cramps):

SIGNS: CLASSIFY AS: TREATMENTS:


Abdominal tenderness with: SEVERE OR • Give appropriate IV/IM
• Fever > 38° C or SURGICAL antibiotics.
• Rebound or ABDOMINAL • Give patient nothing by
• Guarding or mouth (NPO).
PROBLEM • Insert IV.
• Mass or
• Absent bowel sounds or • Refer URGENTLY to hospital *.
• Not able to drink or • If bleeding, follow other
• Pulse > 110 or guidelines for bleeding in
early pregnancy; consider
• Recent missed period or ectopic pregnancy.
abnormal bleeding
• Lower abdominal PID (pelvic • Give ciprofloxacin
tenderness or inflammatory plus doxycycline plus
• Cervical motion metronidazole.
tenderness disease) • Follow up in 2 days if not
improved; follow up all at
7 days (p. 66).
• Promote/provide condoms.
• Offer HIV/STI counselling and
HIV and syphilis testing
• Treat partner for GC/
chlamydia.
• Abstain from sex during
treatment.
• Abdomen soft and none GASTRO-ENTERITIS • If diarrhoea, see p. 32.
of the above signs OR OTHER GI OR • If constipation, advise
GYN PROBLEM remedies. (See Palliative
Care.)
• Return if not improved.
Use this table if suspect gonorrhoea/chlamydia based on any
of these factors
• Sex worker or POSSIBLE • Treat woman and partner
• Bleeding on sexual GONORRHOEA/ with antibiotics for possible
contact or GC/chlamydia infection.
CHLAMYDIA
• Promote/provide condoms.
• Partner with urethral INFECTION • Offer HIV/STI counselling and
discharge or burning on
HIV and syphilis testing.
urination or
• Follow up in 7 days if
• Any woman who thinks symptoms persist (p. 65).
she may have a STI

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37
Use this table in all women with abnormal vaginal discharge:

SIGNS: CLASSIFY AS: TREATMENTS:


• Itching or CANDIDA VAGINITIS • Treat with nystatin.
• Curd-like vaginal • Return if not resolved.
discharge • Consider HIV-related illness
if recurrent (p. 54).
• None of the above BACTERIAL • Give metronidazole 2 gm
VAGINOSIS (BV) OR at once
TRICHOMONIASIS • Follow up in 7 days
if not resolved. (p. 66)

Use this table in all women with burning or pain on urination or flank pain:

• Flank pain or KIDNEY INFECTION If systemically ill:


• Fever. • Give appropriate IM
antibiotics.
• Refer URGENTLY to hospital.
Also refer if on indinavir
(an ARV drug).
If not:
• Give appropriate oral
antibiotics.
• Follow up next day. (p. 66)
• Burning or pain on BLADDER • Give appropriate oral
urination and INFECTION antibiotics.
• Frequency and • Increase fluids.
• No abnormal vaginal • Follow up in 2 days if not
discharge improved. (p. 66)
• None of the above BLADDER • Treat for vaginitis if abnormal
INFECTION discharge.
UNLIKELY • Dipstick urine if possible.

38
Use this table in all women with menstrual pain or missed period or
bleeding irregular or very heavy period:
SIGNS: CLASSIFY AS: TREATMENTS:
• Irregular bleeding PREGNANCY- • Follow guidelines for vaginal bleeding
and RELATED in pregnancy (e.g. IMPAC *) or
• Sexually active or BLEEDING OR • Refer
• Any bleeding in ABORTION
known pregnancy
• Missed period POSSIBLE • Confirm pregnancy.
and PREGNANCY • Discuss plans for pregnancy.
• Sexually active • If she wishes to continue pregnancy,
and use guidelines for antenatal care
• Not using a very (e.g. IMPAC**).
reliable method • Refer or provide PMTCT interventions if
of contraception*. pregnant.
Not pregnant with: IRREGULAR • Consider contraceptive use and need
• New, irregular MENSES OR VERY (see Family Planning guidelines):
menstrual HEAVY PERIODS - If contraception desired, suggest
bleeding or (MENORRHAGIA) oral contraceptive pill.
• Soaks more than - IUD in the first 6 months and
6 pads each of long-acting injectable contraceptive
3 days (with or can cause heavy bleeding; combined
without pain) contraceptive pills or the mini-pill
can cause spotting or bleeding
between periods.
• If on ART, consider withdrawal bleeding
from drug interaction. (See Chronic HIV
Care module.)
• Refer for gynaecological assessment
if unusual or suspicious bleeding in
women > 35 years.
• If painful menstrual cramps or to
reduce bleeding, give ibuprofen
(not aspirin).
• Follow up in 2 weeks.
• Only painful DYSMENORRHOEA • If she also wants contraception, suggest
menstrual cramps oral contraceptive pill.
• Give ibuprofen. (Aspirin or paracetamol
may be substituted but are less
effective.)
* Very reliable methods include injectable, implant, IUD, pills, sterilization.
** WHO Integrated Management of Pregnancy and Childbirth (IMPAC)
39
If patient has a skin problem or lump:

IF YES, ASK: LOOK AND FEEL


If enlarged
• Do you have a sore, a • Are there lesions? lymph nodes
skin problem or Where? or mass:
a lump? How many?
If yes, where is it? Are they infected
(red, tender, warm,
If yes, for how long?
pus or crusts)?
• Does it itch? • Are they tender?
• Does it hurt? • Is there sensation to Is it
light touch? infected?
• Duration?
Consider
• Discharge? • Feel for fluctuance.
• Feel for lymph nodes. this in all
• Do other members of skin lesions.
the family have the Are they tender?
same problem?
• Are you taking any
medication?

If on ARV therapy,
skin rash could be a • Look/feel for lumps.
serious side effect. See
Chronic HIV Care. If painful inguinal
node or ano-genital
ulcer or vesicles, If red, tender,
see p. 20. warm, pus
or crusts
(infected skin
If dark lumps, lesion):
consider HIV-related
illness, see p. 54.

If itching-skin problem,
use p. 42.
If skin sores, blisters or
pustules, use p. 43.
If skin patch with no
symptoms or loss of
feeling, use p. 44.

40
Use this table if enlarged lymph nodes or mass:

SIGNS: CLASSIFY AS: TREATMENTS:


• Size > 4 cm or SUSPICIOUS LYMPH • Refer for diagnostic
• Fluctuant or NODE OR MASS work at district hospital.
• Hard or • Consider TB.
• Fever
• Nearby infection, which REACTIVE • Give oral antibiotic.
could explain lymph node LYMPHADENOPATHY • Follow up in 1 week.
or
• Red streaks
• > 3 lymph node groups PERSISTENT • Do RPR test for syphilis if
with: GENERALIZED none recently.
— > 1 node LYMPHADENOPATHY • Consider HIV-related
illness (p. 54).
— > 1 cm
— 1 month duration
— No local infection to
explain

Is it infected? Ask this in all skin lesions. If yes, also use the infection classification
table below.

Use this table if lesion red, tender, warm, pus or crusts


(infected skin lesion):
• Fever or SEVERE SOFT TISSUE OR • Refer to hospital.
• Systemically unwell or MUSCLE INFECTION • Start IV/IM antibiotics. (If
• Infection extends to not available, give oral
muscle cloxacillin.)
• Consider HIV-related
illness.
• Size > 4 cm or SOFT TISSUE INFECTION • Start cloxacillin.
• Red streaks or OR FOLLICULITIS • Drain pus if fluctuance.
• Tender nodes or • Elevate the limb.
• Multiple abscesses • Follow up the next day.
• Only red, tender, warm, IMPETIGO OR MINOR • Clean sores with
pus or crusts—none of ABSCESS antiseptic.
the signs in the pink or • Drain pus if fluctuance.
yellow row
• Follow up in 2 days.

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41
Use this table if itching skin problems:*
Scabies Papular Eczema Ringworm Dry itchy
itching rash (tinea) skin (xerosis)
(prurigo)
Rash and Itching rash with Wet, oozing Pale, round, bald Dry and rough
excoriations on small papules and sores or scaling patches skin, sometimes
torso; burrows scratch marks. excoriated, thick on scalp or with fine cracks.
in webspace Dark spots with patches. round patches
and wrist; face pale centers. with thick edge
spared. on body or web
of feet.

• Manage • Treat itching. • Soak sores • Whitfield’s • Emollient


with benzyl • Locally effective with clean ointment lotion or
benzoate remedies. water to (or other calamine
(p.86). remove crusts antifungal lotion;
• Give (no soap). cream) if few continue if
• Treat itching. chlorpheni-
• Dry the skin patches. effective.
• If persistent, ramine 4 mg
consider HIV- every 8 hours or gently. • If extensive, • Locally
related illness promethazine • Short term: give effective
(p. 54). hydrochloride use topical ketoconazole remedies.
25 mg at night. steroid cream or griseofulvin. • Give
• Consider HIV- (not on face). • If in hairline, chlorpheni-
related illness • Treat itching. shave hair. ramine or
(p. 54). • Treat itching. promethazine.
• Consider HIV- • Consider HIV-
related illness related illness
(p. 54). (p. 54).

* Seborrhoea may itch – see p. 44.

Is it infected? Ask this in all skin lesions. If yes, also


use the infection classification table on page 41.

42
Use this table if blister, sore or pustules:
Contact Herpes zoster Herpes Drug Impetigo
dermatitis simplex reaction or
folliculitis
Limited to Vesicles in 1 area on Vesicular lesion or Generalized red, Red,
area in contact 1 side of body plus sores, also involving widespread with tender,
with problem intense pain; lips and/or small bumps warm
substance. or scars plus mouth—see p. 24. or blisters; or crusts
shooting pain. 1 or more dark or small
Early: blistering,
In children, primary skin areas (fixed lesions.
red.
herpes simplex drug reaction).
Later: thick, dry,
scaly. presents with many
small sores or ulcers
in mouth, with or
without fever and
lymphadenopathy;
usually resolves
within 2 weeks.

• Hydrocortisone • Keep clean and • If ulceration for > • Stop See


1 % ointment dry; use local 30 days, consider medications. infection
or cream. antiseptic. HIV related illness. • Give table on p.
• If severe • If eye involved • If first or severe chlorpheni- 41.
reaction or any suspicion ulceration, give ramine or
with blisters, encephalitis, give aciclovir. promethazine
exudate or aciclovir 800 mg • Maintain fluid HCl.
oedema, give 5 times daily x 7 intake. • If peeling
prednisone. days. rash with
• Give liquid food
• Find and • Pain relief— and pain relief as involvement
remove cause. analgesics required. of eyes and/or
and low dose mouth—refer
amitriptiline. urgently to
• Offer HIV hospital.
counselling and • Give
testing. Consider prednisone
HIV-related if severe
illness. Discuss reaction or
the possible HIV any difficulty
illness. (p. 54). breathing –
• Follow up in refer urgently
7 days if sores to hospital.
not fully healed,
earlier if worse.

Is it infected? Ask this in all skin lesions. If yes, also use


the infection classification table on page 41.

43
Use this table if skin rash with no or few symptoms:

No or few symptoms
Leprosy Seborrhoea Psoriasis Molluscum Warts
Skin patch(es) Red, thickened contagiousum Small lumps
with: Greasy scales and scaling Raised dome- or bumps
and redness, patches (may shaped lumps with rough
• No sensation
on central face, itch in some). which may have surface.
to light touch,
scalp, body folds, Often on knees a dimple in the May appear
heat or pain.
and chest. and elbows, center. Usually anywhere
• Any location. scalp and on face, neck, (see p. 20
• Pale or reddish hairline, lower armpits, hands. for genital
or copper- back. In adults, on the warts).
colored. genitals.
• Flat or raised or
nodular.
• Chronic (> 6
months).
• Not red or itchy
or scaling.
• Treat with • Ketoconazole • Coal tar • Freeze with • Freeze
leprosy MDT shampoo ointment 5% silver nitrate with liquid
(multidrug (alternative: in salicylic or scrape. Do nitrogen,
therapy) if no keratolytic acid 2%. not treat fascial salicylic
MDT in past shampoo with • Expose to molluscum acid or
(see Chronic salicylic acid as may get silver
sunlight
Care module or or selenium scarring. nitrate.
30-60
other leprosy sulfide or coal Do not
minutes/day. • Consider
guidelines). tar). Repeated treat facial
HIV-related
treatment warts as
illness (p. 54),
may be may get
especially
needed. scarring.
if giant or
• If severe, extensive. • If severe,
topical consider
steroids HIV-
or trial related
ketoconazole. illness
(p. 54).
• Consider HIV-
related illness
(p. 54).

Is it infected? Ask this in all skin lesions. If yes, also


use the infection classification table on page 41.

44
See Adolescent Job Aid for acne.

If on ARV therapy, see Chronic HIV Care


module and consult. Skin reactions are
potentially serious.

See other guidelines for:


• Tropical ulcer.
• Other skin problems not included
here.

List it as, "other skin problem", if you


don’t know what it is. Consult.

45
If patient has a headache or neurological problem:
IF YES, ASK: LOOK AND FEEL

• Do you have weakness in any part of your body? Assess for focal If acute
• Have you had an accident or injury involving neurological headache or
loss of body
your head recently? problems:
function:
• Have you had a convulsion? • Test strength.
• Assess alcohol/drug use. • Look at face:
• Are you taking any medications? flaccid on one
• Do you feel like your brain/mind is working more side?
slowly? • Problem
• Do you have trouble keeping your attention on walking?
any activity for long? • Problem talking?
• Do you forget things that happened recently? • Problem moving
• Ask family: eyes?
If delusions
— Has the patient’s behaviour changed? • Flaccid arms or
or bizarre
— Is there a memory problem? legs?
thoughts,
— Is patient confused? - If yes, loss of
see p. 50.
If memory problem by patient or family strength?
report, tell patient you want to check • Feel for stiff
his/her memory: neck.
— Name 3 unrelated objects, clearly and slowly. • Measure BP.
Ask patient to repeat them: • Is patient
— Can he/she repeat them? confused?
(registration problem?)
If yes, wait 5 minutes and again ask, "Can you If patient reports
recall the 3 objects?" (recall problem?) weakness, test
If confused: strength.

— When did it start? If headache, feel for If painful feet


— Determine if patient is oriented to place sinus tenderness. or legs:
and time.
If confused or
• If headache:
disoriented, look
— For how long?
for physical cause,
— Visual defects? alcohol or drug or If cognitive
— Vomiting? medication toxicity, problems,
see p. 48.
— On one side? or withdrawal.
— Prior diagnosis of migraine?
— In HIV patient, new or unusual headache?

46
Use this table if headache or neurological problem:
SIGNS: CLASSIFY AS: TREATMENTS:
• Loss of body functions or SERIOUS • Refer urgently to hospital.
• Focal neurological signs or NEURO- • If stiff neck or fever, give IM antibiotics
• Stiff neck or LOGICAL and IM antimalarial.
• Acute confusion or PROBLEM • If flaccid paralysis in adolescent
• Recent head trauma or < 15 years, report urgently to EPI
• Recent convulsion or programme.
• Behavioural changes or • If recent convulsion, have diazepam
available during referral.
• Diastolic BP > 120 or
• Consider HIV-related illness (p. 54).
• Prolonged headache
(> 2 weeks) or
• In known HIV patient:
— Any new unusual
headache or
— Persistent headache
more than 1 week
• Tenderness over sinuses SINUSITIS • Give appropriate oral antibiotics.
• Give ibuprofen.
• If recurrent, consider HIV-related illness
(p. 54).
• Repeated headaches with MIGRAINE • Give ibuprofen and observe response.
- Visual defects or • If more pain control is needed, see
- Vomiting or Palliative Care guidelines on acute pain.
- One-sided or
- Migraine diagnosis
• None of the above TENSION • Give paracetamol.
HEADACHE • Check vision–consider trial of glasses.
• Suggest neck massage.
• Reduce: stress, alcohol and drug use.
• Refer if headache more than 2 weeks.
• If on ARV drugs, this may be a side
effect. (See Chronic HIV Care.)

Use this table if painful leg neuropathy


• Painful burning or numb PAINFUL LEG • If on INH, give pyridoxine. If chronic
or cold feeling in feet or diarrhoea, try ORS.
NEUROPATHY
lower legs • Consider HIV-related illness (p. 54),
syphilis (do RPR, p.118); diabetes (check
blood or urine for glucose); ART side
effect—see Chronic HIV Care.
• Refer for further assessment if cause
unclear.
• Treat with low-dose amitriptyline
(p. 82).
• Follow up in 3 weeks.

go to next page
47
Use if cognitive problems—problems thinking or remembering or
disorientation:

SIGNS: CLASSIFY AS: TREATMENTS:


• Recent onset of DELIRIUM • Refer to hospital.
confusion or • Give antimalarial pre-referral if
• Difficulty speaking or malaria risk (p. 70).
• Loss of orientation or • Give glucose and thiamine. (Check
• Restless and agitated or blood glucose.)
• Reduced level of • Treat physical cause (systemic
consciousness illness) or alcohol (p. 52) or drug/
medication toxicity or withdrawal.
• Consider HIV-related illness (p. 54).
If HIV-related, may improve on ARV
therapy.
• If not able to refer, also give fluids.
• If very agitated and not alcohol
or drug intoxicated, give low dose
sedation with haloperidol (p. 83).
No reduced level of DEMENTIA • Consult or refer for assessment if
consciousness with: cause uncertain. Every patient with
• Serious memory dementia needs a full assessment
problems or once to exclude a reversible cause.
• Slowed thinking with • Consider HIV-related illness (p. 54)
trouble keeping attention If HIV-related, may improve on ARV
or therapy.
• Misplaces important • Advise family.
objects or • In elderly, make sure adequately
• Loss of orientation or hydrated.
• Slowed thinking with • If known diagnosis, arrange for
trouble keeping attention home care support to provide
a safe, protective environment.
Supportive contact with familiar
people can reduce confusion.
• Occasional decreased NORMAL • Reassure patient and relatives.
concentration or AGING
• Minor short term
memory loss

48
NOTES:

49
If patient has a mental problem, looks depressed or
anxious, sad, fatigued, alcohol problem or recurrent
multiple problems:

IF YES, ASK: LOOK AND FEEL If sad or loss


of interest or
How are you feeling? (Listen • Does patient appear: decreased
without interrupting.) energy:
— Agitated?
Ask: — Restless?
— Do you feel sad or — Depressed?
depressed? • Is patient disoriented to time
— Have lost interest/pleasure and place?
in things you usually
enjoy? • Is patient confused?
— Do you have less energy • Does the patient express
than usual? bizarre thoughts? If yes,
If yes to any of the above — Does the patient express
three questions, ask for these incredible beliefs
depression symptoms: (delusions) or see or hear If tense, anxious, or
things others cannot excess worrying,
— disturbed sleep
(hallucinations)? p. 52.
— appetite loss (or increase)
— poor concentration — Is the patient intoxicated If more than 21
— moves slowly with alcohol or on drugs drinks/week for
— decreased sex drive which might cause these men, 14 for women
— loss of self-confidence problems? or drunk more than
or esteem • Does patient have a tremor? twice in last year,
p. 52.
— guilty feelings
— thoughts of suicide or If fatigue or loss of
death energy, consider
Have you had bad news for medical causes of
yourself or your family? fatigue such as anaemia
(p. 18), infection,
If suicidal thoughts, assess the medications, lack of
risk:
exercise, sleep problems,
— Do you have a plan? fear of illness, HIV
— Determine if patient has disease progression.
the means.
— Find out if there is a fixed
time-frame. If confusion or cognitive
— Is the family aware? problems, see p. 48.
— Has there been an
attempt? How? Potentially If bizarre
lethal? thoughts:
If HIV patient, consider
Do you drink alcohol? If yes: underlying medical
— Calculate drinks per week problem or drug toxicity
over last 3 months. for any new change in
— Have you been drunk more mental status.
than 2 times in past year?

50
Use this table if sad or loss of interest or decreased energy:

SIGNS: CLASSIFY AS: TREATMENTS:


• Suicidal thoughts SUICIDE RISK • If high risk, refer for hospitalization (if
If patient also available) or arrange to stay with family
has a plan and or friends (do not leave alone).
the means, or • Manage the suicidal person.
attempts it with • Remove any harmful objects.
lethal means,
consider high risk • Mobilize family support.
• Follow up.
• Five or more MAJOR • If suspect bipolar disorder (manic at
depression DEPRESSION other times), refer for lithium.
symptoms and • If patient is taking efavirenz (EFV), see
• Duration more Chronic HIV Care.
than 2 weeks • Otherwise, start amitryptiline (p. 82).
• Educate patient and family about
medication.
• Refer for counselling if available or
provide basic counselling to counter
depression (see p. 107-108).
• Follow up.
• Less than 5 MINOR • Counsel to counter depression.
depression DEPRESSION/ • Give amitryptyline if serious problem
symptoms or COMPLICATED with functioning.
• More than BEREAVEMENT
• If problems with sleep, suggest solutions.
2 months of
bereavement • Follow up in 1 week.
with functional
impairment
• Bereaved, DIFFICULT LIFE • Counsel, assure psychosocial support.
but functioning EVENTS/LOSS • If acute, uncomplicated bereavement
with high distress and not able to sleep,
give diazepam 5 mg or amitryptiline 25
mg at night for one week only.

Use this table in all with bizarre thoughts:


• Delusions POSSIBLE • Exclude alcohol intoxication or drug
• Hallucinations PSYCHOSIS toxicity or ARV side effect
(especially EFV).
• Consider infection and other
causes—see Delirium, p. 48.
• Refer for psychiatric care.
• If acutely agitated or dangerous to self
or others, give haloperidol (p. 83).

51
Use this if tense, anxious or excess worrying:

SIGNS: CLASSIFY AS: TREATMENTS:


• Sudden episodes of ANXIETY DISORDER • Counsel on managing
extreme anxiety or anxiety according to
• Anxiety in specific specific situation.
situations or • Teach patients
• Exaggerated worry or slow breathing and
progressive relaxation.
• Inability to relax or
• If severe anxiety, consider
• Restlessness short-term use of
diazepam (up to 2 weeks
only). Refer if severe
anxiety > 1 month.
• Follow up in 2 weeks.

Use this if more than 21 drinks/week for men, 14 for women or drunk
more than twice in last year:

Two or more of: SEVERE WITHDRAWAL • Refer to a treatment


• Severe tremors SIGNS center or hospital.
• Anxiety • Give diazepam for
withdrawal if not able to
• Hallucinations refer; monitor daily.
• Give thiamine to all, and
glucose if poor nutrition.
• Possible excessive alcohol HAZARDOUS ALCOHOL • Assess further using
use USE WHO AUDIT and counsel.
(Use brief intervention
guidelines for hazardous
alcohol use.)

Assess and treat other problems

If:
• pain from chronic illness,
• constipation,
• hiccups, and/or
• trouble sleeping,
see Palliative Care module.
If chronic illness, see Chronic Care modules.

52
Consider HIV-Related
Illness

Consider
HIV-related Illness

53
Consider HIV-Related
Illness

Clinical Signs of Possible HIV Infection


• Repeated infections
• Herpes zoster
• Skin conditions including prurigo, seborrhoea
• Lymphadenopathy (PGL)—painless swelling in neck and armpit
• Kaposi lesions (painless dark or purple lumps on skin or palate)
• Severe bacterial infection—pneumonia or muscle infection
• Tuberculosis—pulmonary or extrapulmonary
• Oral thrush or oral hairy leukoplakia
• Gum/mouth ulcers
• Oesophageal thrush
• Weight loss more than 10 % without other explanation
• More than 1 month:
— Diarrhoea (unexplained)
— Vaginal candidiasis
— Unexplained fever
— Herpes simplex ulceration (genital or oral)

Other indications suggesting possible infection:


• Other sexually transmitted infections
• A spouse or partner or child:
— known to be HIV positive
— has HIV or HIV-related illness
• Unexplained death of young partner
• Injecting drug use
• High risk occupation
• Sexually active person with multiple partners living in high
HIV-burden area

54
Consider TB and send sputums for examination of TB
(p. 112) if any of these signs:

• Cough for more than 2 weeks


• Father, mother, partner, or sibling diagnosed as TB
• Weight loss
• Hemoptysis
• Painless swelling in neck or armpit
• Sweats
• Weight loss

❖ If HIV status is unknown, advise to be tested for HIV


infection. (See p. 97)

❖ If patient has signs in bold in the gray box on the previous


page:
• These signs indicate HIV clinical stage 3 or 4. Patient is likely
eligible for ARV therapy. HIV testing is urgent (see Chronic HIV
Care module).

❖ For patients with a positive HIV test:


• Obtain a CD4 count if available.
• Provide ongoing HIV Care—use the Chronic HIV Care module.

55
56
Prevention:
Screening and Prophylaxis

Prevention:
Check Status of
Routine Screening,
Prophylaxis and
Treatment
Do this in all acute and chronic patients!

57
Prevention:
Screening and Prophylaxis

ASSESS TREAT AND ADVISE


• Ask whether patient and family are • Encourage use of insecticide-treated
sleeping under a bednet. bednets.
- If yes, has it been dipped in
insecticide?
• Is patient sexually active? (For • Counsel on safer sex. See next page
adolescent: Have you started having for adolescents.
sex yet? See next page.) • Offer family planning.
• Determine if patient is at risk for HIV • If unknown status:
infection.
- offer HIV testing and explain its
• Is patient’s HIV status known? advantages (p. 97), and
- counsel after HIV testing.
• Does patient smoke? If yes, counsel to stop smoking. (See
• If adolescent, do you feel pressure to Brief Interventions: Smoking Cessation.)
do so? • If adolescent is smoking: educate
on hazards, help to say no. If not,
provide positive reinforcement.
• Does patient drink alcohol? If yes, • If more than 21 drinks/week for men,
calculate drinks per week over last 14 for women or 5 drinks at once,
3 months. assess further and counsel to reduce
• Have you had 5 or more drinks on or quit. (See Brief Interventions:
1 occasion in last year? Hazardous Alcohol.)
• If adolescent is drinking: educate on
hazards, help to say no. If not, provide
positive reinforcement.
• Has patient over 15 years been • Measure blood pressure. Repeat
screened for hypertension within last measurement if systolic >120 mmHg.
2 years? • If still elevated, see hypertension
guidelines.
• Occupation with back strain or • Exercises to stretch and strengthen
history of back pain. abdomen and back.
• Correct lifting and other preventive
interventions.

58
ASSESS TREAT AND ADVISE
In adolescent girls and women of Give mebendazole if due.
childbearing age: If Tetanus Toxoid (TT) is due:
Check Tetanus Toxoid (TT) immunization • give 0.5 ml IM, upper arm.
status: • advise her when next dose is due.
- When was TT last given? • record on her card.
- Which doses of TT was this? TETANUS TOXOID (TT or Td) SCHEDULE:
- Check when last dose mebendazole. • At first contact with woman of childbearing
age or at first antenatal care visit, as early as
possible during pregnancy.
• At least four weeks after TT1 —>TT2.
• At least six months after TT2 —>TT3.
• At least one year after TT3 —>TT4.
• At least one year after TT4 —>TT5.

In women of childbearing age: • If pregnant, discuss her plans, follow


- Is she pregnant? antenatal care guidelines.
• If not pregnant, offer family planning.

Special Prevention for Adolescents See Adolescent Job Aid.


ASSESS TREAT AND ADVISE
❖ Is patient sexually active? If no, encourage the patient to delay initiation of penetrative
❖ If yes—sexually active, also vaginal, anal or oral sexual intercourse, and to avoid anything that
ask: brings him/her into contact with his/her partner’s semen or vaginal
— does the patient use secretions.
condoms? ❖ Advise to explore sexual pleasure in other forms of intimacy. Find
— was the patient forced non-sexual activities that you and your partner enjoy.
to have sex? If yes—sexually active, provide information and counselling
— does the patient about the prevention of HIV, STIs and pregnancy, emphasizing that
consider him/herself to condoms are dual protection for pregnancy and STIs/HIV.
be at risk of HIV, other ❖ Advise the patient to reduce the number of partners or, better
STIs or pregnancy? yet, be faithful to one.
— does patient know ❖ Advise to use condoms correctly and consistently every time that
his/her HIV status? s/he has sexual intercourse.
Demonstrate how to use a condom.
Young people may know very ❖ Discuss appropriate ways of saying no to unwanted sex and
little about HIV and how it is negotiating condom use. Reinforce skills to say no. (Refer to an
transmitted. Be sure to check appropriate organization or group if s/he does not have the
their understanding, especially skills.) Make sure girls understand that they cannot tell by looking
about how to protect at someone if the person is infected with HIV and that HIV risk
themselves. increases with the age of the man.
❖ Offer HIV testing and counselling. (See p. 98-99.)
❖ If unprotected sexual intercourse, advise on emergency
contraception within 120 hours and prevention and treatment
of STIs.
❖ If patient has been forced to have sex or raped, see
Quick Check module.

59
Always use condoms
How you should use condoms:

1 Open condoms
and check expiry date.

5 Knot condom to avoid


spilling sperm. Throw
used condom in pit
latrine or burn it.

2 Squeeze air from the


teet of the condom.

4 Hold condom and remove


penis from vagina

3 Roll rim of condom on


erect penis.

Condoms should be put on at the


beginning of intercourse, not just
before ejaculation.

60
Follow-up Care for
Acute Illness

Follow-up Care for


Acute Illness

61
Follow-up Care for
Acute Illness

Follow-up pneumonia

❖ After 2 days, assess the patient:


• Check the patient with pneumonia using the Look and Listen part of the
assessment on page 16.
• Also ask, and use the patient’s record, to determine:
- Is the breathing slower?
- Is there less fever?
- Is the pleuritic chest pain less?
- How long has the patient been coughing?

❖ Treatment:
• If signs of SEVERE PNEUMONIA OR VERY SEVERE DISEASE or no
improvement in pleuritic chest pain, give IM antibiotics and refer
urgently to hospital.
• If breathing rate and fever are the same, change to the second-line oral
antibiotic and advise to return in 2 days.
Exception: refer to hospital if the patient:
- has a chronic disease or
- is over 60 years of age or
- has suspected or known HIV infection
• If breathing slower or less fever, complete the 5 days of antibiotic.
Return only if symptoms persist.

❖ Also:
• If still coughing and cough present for more than 2 weeks, send
3 sputums for TB or send the patient to district hospital for sputum
testing.
• Consider HIV-related illness (p. 54).
• If recurrent episodes of cough or difficult breathing and a chronic lung
problem has not been diagnosed, refer patient to district hospital for
assessment.

62
Follow-up TB: diagnosis based on sputum smear
microscopy (three sputum samples)

If: Then:
Two (or three) samples are positive Patient is sputum smear-positive (has
infectious pulmonary TB). Patients
need TB treatment—see TB Care.
Only one sample is positive Diagnosis is uncertain. Refer patient to
clinician for further assessment.

All samples are negative Patient is sputum smear-negative for


infectious pulmonary TB:
- If no longer coughing, no
treatment is needed.
- If still coughing, refer to a clinician
if available, or treat with a non-
specific antibiotic such as
cotrimoxazole or ampicillin.
If cough persists, repeat
examination of three sputum
smears.

Follow-up fever

If high or low malaria risk—examine malaria smear

If persistent fever—consider:
• TB
• HIV-related illness (See p. 54).
Refer if unexplained fever 7 days or more.

63
Follow-up persistent diarrhoea in HIV
negative patient (for HIV positive, see
Chronic HIV Care module)
• Advise to drink increased fluids (see Plan A, p. 88).
• Continue eating.
• Consider giardia infection—give metronidazole and
follow up in 1 week.
• Stop milk products (milk, cheese).
• If elderly or confined to bed, do rectal exam to exclude
impaction (diarrhoea can occur around impaction).
• If blood in stool, follow guidelines for dysentery.
• If fever, refer.
• If no response, refer. District clinician should evaluate.

Follow-up oral or oesophageal candida


• For suspected oesophagitis—if no response and not able
to refer, give aciclovir if mouth lesions suggest herpes
simplex.
• If not already tested for HIV, encourage testing and
counselling.
• If HIV positive, see Chronic HIV Care module.

Follow-up anogenital ulcer

If ulcer is healed: no further treatment


If ulcer is improving:
• Continue treatment for 7 more days
• Follow up in 7 days
If no improvement: refer

64
Follow-up urethritis in men
Rapid improvement usually seen in a few days with no For all patients
symptoms after 7 days.
• Promote
If not resolved, consider the following: and provide
• Has patient been reinfected? Were partners treated? If not, condoms.
treat partners and patient again.
• Offer HIV
• Make sure treatment for both GC and chlamydia was given testing and
and that patient adhered to treatment. If not, treat again. counselling,
• If trichomonas is an important cause of urethritis locally, p. 98.
treat patient and partner with metronidazole.
• Educate on
• If patient was adherent and no reinfection likely and STIs, HIV
resistant GC is common, give second-line treatment and risk
or refer. reduction.

Follow-up gonorrhoea/chlamydia
infection in women
• Make sure treatment for both GC and chlamydia was given
and that patient adhered to treatment. If not, treat again.
• If abnormal discharge or bleeding on sexual contact
continues after re-treatment, refer for gynaecological
assessment. Persistence of these symptoms after
repeated treatment can be an early sign of cervical cancer,
especially in women > 35 years.

Follow-up candida vaginitis


Some improvement usually seen in a few days with no
symptoms after 7 days of treatment.
If symptoms persist:
• Re-treat patient.
• Ask about oral contraceptive or antibiotic use—these can
contribute to repeated candida infections.
• Consider HIV infection or diabetes, particularly if symptoms
of polyuria or increased thirst or weight loss. Check urine
glucose—if present, refer for fasting blood sugar, repeat
candida infections are common. Consider prophylaxis (H16).
• Consider treating for possible GC/chlamydia infection if not
treated on the first visit.
65
Follow-up bladder infection or menstrual problem
Consider STIs if symptoms persist—treat patient and
partner for GC/chlamydia. Consider use of second-line
antibiotic.
If polyuria continues or is associated with increased thirst
or weight loss, check for diabetes mellitus by dipstick of
urine. If positive for sugar, refer for fasting blood sugar and
further assessment.
Check adherence to treatment.

Follow-up PID
For all patients
Some improvement usually seen in 1-2 days but it may take • Promote
weeks to feel better. (Chronic PID can cause pain for years.) and provide
If no improvement: condoms.
• Consider referral for hospitalization. • Offer HIV
• If IUD in place, consider removal. testing and
counselling,
If some improvement but symptoms persist: p. 98.
• Extend treatment. Make sure partner has been treated for
• Educate on
GC/chlamydia. Follow up regularly and consider referral if
STIs, HIV
still not resolved.
and risk
reduction.

Follow-up BV or trichomonas vaginitis

Some improvement usually seen in a few days with no


symptoms after 7 days.
If symptoms persist:
• Treat patient and partner with 7 days course of
metronidazole at same time.
• Consider treating candida infection and cervicitis if these
were not treated on the first visit.
• For bacterial vaginosis (BV), make sure she avoids
douching or using agents to dry vagina.
• If discharge persists after re-treatment, refer for
gynaecological assessment.

66
Treatment

Treatments
Special advice for prescribing medications for
symptomatic HIV or elderly patients
❖ For some medications, start low, go slow. (Give full dose of
antimicrobials and ARV drugs.)
❖ Expect the unexpected—unusual side effects and drug
interactions.
❖ Need for dynamic monitoring—you may need to adjust
medications with change in weight and illness.
❖ If on ARV therapy, be sure to check for drug interactions
before starting any new medication—see Chronic HIV Care
module.

67
Treatment

Instructions for Giving IM/IV Drugs:


❖ Explain to the patient why the drug is given.
❖ Determine the dose appropriate for the patient’s weight. For some
drugs, it is preferable to calculate exact dose for weight.
❖ Use a sterile needle and sterile syringe for each patient.
❖ Measure the dose accurately.

68
Give benzathine penicillin
For syphilis:
❖ Do not treat again for positive RPR if patient and partner both treated
within last 6 months.
❖ Treat woman and her partner with 2.4 million units benzathine penicillin.
If pregnant, plan to treat newborn.
❖ If allergic to penicillin: give doxycycline 100 mg twice daily for 14 days or
tetracycline 500 mg orally 4 times daily for 14 days.
For rheumatic fever/heart disease (RF/RHD) prophylaxis:
❖ Give 1.2 million units every 4 weeks—see RF/RHD Chronic Care module.

Adolescent or adult BENZATHINE PENICILLIN IM


Add 5 ml sterile water to vial containing 1.2
million units = 1.2 million units/6 ml total
volume
Primary syphilis 12 ml (6 ml in each buttock)
Prophylaxis: RF/RHD 6 ml every 4 weeks
Suspect streptococcal 6 ml once
pharyngitis

Give glucose
❖ Give by IV. Make sure IV is running well. Give by slow IV push.
50% 25% 10%
GLUCOSE GLUCOSE GLUCOSE SOLUTION
SOLUTION * SOLUTION (5 ml/kg)

Adolescent or 25 - 50 ml 50 - 100 ml 125 - 250 ml


Adult

* 50% glucose solution is the same as 50% dextrose solution or D50. This solution is
irritating to veins. Dilute it with sterile water or saline to produce 25% glucose solution.
❖ If no IV glucose is available, give sugar water by mouth or nasogastric tube.
❖ To make sugar water, dissolve 4 level teaspoons of sugar (20 grams) in a
200 ml cup of clean water.

69
Give IM antimalarial
❖ Give initial IM loading dose before referral.
• Artesunate: Give one IM injection.
• Or artemether: Give one IM injection.
• Or quinine: give 20 mg/kg divided equally into two injections—
one in each anterior thigh.

ucose
always give gl
with quinine QUININE IM ARTEMETHER ARTESUNATE
20 mg/kg* 3.2 mg/kg 2.4 mg/kg
(loading dose) (loading dose) (loading dose)
WEIGHT 150 mg/ml 300 mg/ml 80 mg/ml 60 mg/3 ml
(in 2 ml (in 2 ml (in 1 ml (after
ampoules) ampoules) ampoules) reconstitution
with 1 ml of
5% sodium
bicarbonate and
dilution with 2 ml
normal saline)
30-39 kg 4 ml 2 ml 1.2 ml 3.6 ml
40-49 kg 5.3 ml 2.7 ml 1.6 ml 4.8 ml
50-59 kg 6.7 ml 3.3 ml 2.0 ml 6 ml
60-69 kg 8 ml 4 ml 2.4 ml 7.2 ml

* Dosages are appropriate for quinine hydrochloride, quinine dihydrochloride or quinine


sulfate. If quinine base, give 8.2 mg/kg every 8 hours.

❖ If not able to refer, continue treatment as follows:


• After loading dose of artesunate, give 1.2 mg/kg (half of above dose)
IM at 12h and 24h, then once a day until able to take orally, to complete
6 days of treatment.
• After loading dose of artemether, give 1.6 mg/kg (half of above dose)
IM each day until able to take orally, to complete 6 days of treatment.
• After loading dose of quinine, give quinine 10 mg/kg (half of above
dose) every 8 hours until able to take oral medication: give a full course
of an effective antimalarial treatment, preferably of combination therapy,
ACT or quinine plus clindamycin or doxycycline. Regimens containing
mefloquine should be avoided if the patient presented initially with
impaired consciousness.

70
Give diazepam IV or rectally

❖ Call for help to turn and hold patient.


❖ Draw up 4 ml dose from an ampoule of diazepam into a 5 ml
syringe. Then remove the needle.
❖ Insert small syringe 4 to 5 centimeters into the rectum and inject
the diazepam solution.

DIAZEPAM RECTALLY IV
10 mg/2 ml solution 0.2-0.3 mg/kg
0.5 mg/kg
Initial dose 4 ml (20 mg) 2 ml (10 mg)
Second dose 2 ml (10 mg) 1 ml (5 mg)

❖ Hold buttocks together for a few minutes.

If convulsion continues after 10 minutes, give a second, smaller


dose of 1 ml diazepam IV or 2 ml rectally.

Maintenance dose during transportation if needed and health


worker accompanies:
• 2 ml rectal dose can be repeated every hour during emergency
transport or
• Give slow IV infusion of 10 mg diazepam in 150 ml over 6 hours.

Stop the maintenance dose if breathing less than 16 breaths per


minute. If respiratory arrest, ventilate with bag and mask.

Maximum total dose diazepam: 50 mg.

71
Give appropriate IV/IM antibiotic pre-referral
Classification Antibiotic

Severe First-line antibiotic:


Pneumonia, Very ______________________
Severe Disease (Common choice: benzylpenicillin plus gentamicin)
Second-line antibiotic:
______________________
(Common choice: chloramphenicol)

Very Severe First-line antibiotic:


Febrile Disease or ______________________
suspect sepsis (Common choice: chloramphenicol)
Second-line antibiotic:
______________________
(Common choice: benzylpenicillin plus gentamicin;
or ceftriaxone)

Severe soft First-line antibiotic:


tissue, muscle, or ______________________
bone infection (Common choice: cloxacillin)
or suspected Second-line antibiotic:
Staphylococcal ______________________
infection (Common choice: )

Severe or surgical First-line antibiotic:


abdomen ______________________
(Common choice: ampicillin plus gentamicin plus
metronidazole)
Second-line antibiotic:
______________________
(Common choice: ciprofloxacin plus metronidazole)

Kidney infection First-line antibiotic:


______________________
(Common choice: ampicillin plus gentamicin)
Second-line antibiotic:
______________________
(Common choice: ciprofloxacin)

72
IV/IM antibiotic dosing
WEIGHT BENZYLPENICILLIN GENTAMICIN
Dose: 50 000 units per kg. Dose: 5 mg/kg/day.
Calculate EXACT dose based on body
weight. Only use these doses if this is
not possible.
To a vial of 600 mg (1 000 Vial containing 20 Vial containing 80
000 units): Add 2.1 ml mg = 2 ml at 10 mg = 2 ml at 40
sterile water = 2.5 ml at mg/ml undiluted mg/ml undiluted
400 000 units/ml
30-39 kg 4 ml 15-19 ml 4-5 ml
40-49 kg 6 ml 20-24 ml 5-6 ml
50-59 kg 7 ml 25-29 ml 6-7 ml
60-69 kg 8 ml 30-34 ml 7.5-8.6 ml
If not able to refer: Give If not able to refer: Give above dose
above dose IV/IM every 6 once daily
hours

CHLORAMPHENICOL CLOXACILLIN AMPICILLIN


Dose: 40 mg per kg Dose: 25-50mg/kg Dose: 50mg/kg
WEIGHT Add 5.0 ml sterile IV: To a vial of 500 mg To a vial of 500
water to vial add 8 ml of sterile water mg add 2.1 ml
containing 1000 mg = to give 500 mg/10 mls sterile water =
5.6 ml at 180 mg/ml IM: Add 1.3 ml of sterile 2.5 ml for 500
water to a vial of 250 mg mg
to give 250 mg/1.5 ml
30-39 kg 8 ml 6-12 ml IM (20-40 ml IV) 10 ml
40-49 kg 10 ml 7.5-15 ml IM (25-50 ml IV) 12 ml
50-59 kg 12 ml 9-18 ml IM (30-60 ml IV) 15 ml
60-69 kg 14 ml 10-20 ml IM (35-70 ml IV) 18 ml
If not able to refer: If not able to refer: Give If not able to
Give above dose IV/ above dose IV/IM every refer: Give
IM every 12 hours 4-6 hours above dose
IV/IM every
6 hours

73
Give salbutamol by metered-dose inhaler

100 mcg/puff ; 200 doses/inhaler


Use spacer and/or mask depending on patient.
❖ If SEVERE WHEEZING with severe respiratory distress: give 20 puffs of
salbutamol in a row. If possible, give continuously by nebulizer.
If no response in 10 minutes, give epinephrine. *
❖ If MODERATE WHEEZING or SEVERE WHEEZING without severe
respiratory distress:
2 puffs every 10 minutes x 5 times, then
2 puffs every 20 minutes x 3 times, then
2 puffs every 30 minutes x 6 times, then
2 puffs every 3, 4 or 6 hours
❖ If MILD WHEEZING: 2 puffs every 20 minutes x 3 times, then 2 puffs
every 3 to 6 hours.

* For further management of wheezing, see Quick Check module or asthma


guidelines.

74
Instructions for Giving Oral Drugs
TEACH THE PATIENT HOW TO TAKE ORAL DRUGS AT HOME

❖ Determine the appropriate drugs and dosage for the patient’s age
and weight.
❖ Tell the patient the reason for taking the drug.
❖ Demonstrate how to measure a dose.
❖ Watch the patient practice measuring a dose by himself.
❖ Ask the patient to take the first dose.
❖ Explain carefully how to take the drug, then label and package the
drug.
❖ If more than 1 drug will be given, collect, count and package each
drug separately.
❖ Explain that all the oral drug tablets must be used to finish the
course of treatment, even if the patient gets better.
❖ Support adherence.
❖ Check the patient’s understanding before s/he leaves the clinic.

75
Give appropriate oral antibiotic
For pneumonia if age 5 years up to 60 years
First-line antibiotic: ______________________
(Common choice: penicillin VK (oral) or cotrimoxazole)
Second-line antibiotic: ______________________
(Common choice: amoxicillin or erythromycin)
For pneumonia if age greater than 60 years
First-line antibiotic: ______________________
(Common choice: amoxicillin or cotrimoxazole)
Second-line antibiotic: ______________________
(Common choice: amoxicillin-clavulanate)
For dysentery
First-line antibiotic: ______________________
(Common choice: nalidixic acid or ciprofloxacin)
Second-line antibiotic: ______________________
For cholera - single dose treatment
First-line antibiotic: ______________________
(Common choice: tetracycline or doxycycline)
Second-line antibiotic: ______________________
(Common choice: ciprofloxacin or erythromycin)
For abscess, soft tissue infection, folliculitis, dental abscess
First-line antibiotic: ______________________
(Common choice: cloxacillin)
Second-line antibiotic: ______________________
For chancroid (treat for 7 days)
First-line antibiotic:______________________
(Common choice: ciprofloxacin or erythromycin)
Second-line antibiotic: ______________________
For lymphogranuloma venereum, treat for 14 days
First-line antibiotic: ______________________
(Common choice: doxycycline)
Second-line antibiotic: ______________________
For reactive lymphadenopathy
First-line antibiotic: ______________________
Second-line antibiotic: ______________________
For outpatient treatment PID
First-line antibiotic:______________________
(Common choice: ciprofloxacin and doxycycline and metronidazole)
Second-line antibiotic: ______________________
For bladder infection
First-line antibiotic:______________________
(Common choice: cotrimoxazole)
Second-line antibiotic: ______________________

76
COTRIMOXAZOLE AMOXICILLIN CLOXACILLIN
(trimethoprim + Give 3 daily for 5 days Give 4 times
sulfamethoxazole) daily for 5
Give 2 times daily for days
5 days
AGE or ADULT TABLET TABLET TABLET TABLET
WEIGHT 80 mg trimethoprim 500 mg 250 mg 500 mg
+ 400 mg
sulfamethoxazole
5 years to
13 years 1 1/2 1 1
(19-50 kg)
14 years
or more (> 2 1 2 1
50 kg)

DOXYCYCLINE * ERYTHROMYCIN PEN VK CIPRO-


Give 2 times Give 4 times daily Give 3 FLOXACIN
daily for 5 for 5 days times Give 2 times
days (avoid daily for daily for 7 to 14
doxycycline 5 days days
in young
adolescents)
AGE or TABLET TABLET TABLET TABLET TABLET
WEIGHT 100 mg 500 mg 250 mg 500 mg 500 mg
5 years
to 13
years 1 1/2 1 1 I/2
(19-50
kg)
14 years
or more 1 1 2 1 1
(> 50 kg)

* Avoid doxycycline under 12 years.

77
Give antibiotics for possible GC/chlamydia infection

IN NON-PREGNANT WOMAN, OR MAN:

First-line antibiotic combination for GC/chlamydia: _________________


________________________

(Common choice: ciprofloxacin plus doxycycline)

Second-line antibiotic combination if high prevalence resistant GC or


recent treatment: ________________________________

IN PREGNANT WOMAN:

First-line antibiotic combination for GC/chlamydia:_________________


_______________________

(Common choice: cefixime plus amoxicillin)

Second-line antibiotic combination if high prevalence resistant GC or


recent treatment: _______________________________

Antibiotics for gonorrhoea (GC)


SAFE FOR USE IN PREGNANCY: 125 mg IM
Ceftriaxone
Cefixime 400 mg 1 tablet in clinic
Spectinomycin 2 grams IM
Kanamycin 2 grams IM
NOT SAFE FOR USE IN PREGNANCY:
Ciprofloxacin 250 mg 2 tablets in clinic
500 mg 1 tablet in clinic

78
Antibiotics for chlamydia
SAFE FOR USE IN PREGNANCY:
Amoxicillin 500 mg 1 tablet 3 times daily for 7 days
250 mg 2 tablets 3 times daily for 7 days
Azithromycin 250 mg 4 capsules in clinic
Erythromycin base 250 mg 2 tablets 4 times daily for 7 days
base 500 mg 1 tablet 4 times daily for 7 days
NOT SAFE FOR USE IN PREGNANCY
OR DURING LACTATION:
Doxycyline 100 mg 1 tablet 2 times daily for 10 days

Tetracycline 500 mg 1 tablet daily for 10 days

Give metronidazole
Advise to avoid alcohol when taking metronidazole
❖ For bacterial vaginosis or trichomoniasis

METRONIDAZOLE
250 mg tablet
Adolescent or adult 2 grams (8 tablets) at once in clinic or 2
tablets twice daily for 7 days

❖ For persistent diarrhoea, bloody diarrhoea, PID or severe gum/mouth


infection:

Weight METRONIDAZOLE METRONIDAZOLE


250 mg tablet twice daily 500 mg tablet twice
for seven days daily for 7 days
Adolescent or
adult 2 1

79
Give appropriate oral antimalarial
First-line antimalarial: ______________________
Second-line antimalarial: ____________________

AGE or WEIGHT ARTESUNATE + ARTEMETHER/ SULFADOXINE/ ARTESUNATE


AMODIAQUINE LUMEFANTRINE PYRIMETHAMINE daily for 3 days +
daily dose, twice daily for (SP) Single dose in MEFLOQUINE split
once daily 3 days* clinic + ARTESUNATE over the 2nd and
for 3 days daily for 3 days** 3rd days

Separate Coformulated Separate tablets: Separate tablets:


tablets: tablet: SP tablet artesunate tablet
artesunate artemether (sulfadoxine 500 mg (Art) 50 mg;
tablet 50 mg; 20 mg + + pyrimethamine mefloquine tablet
amodiaquine lumefantrine 25 mg); artesunate (Mef) 250 mg base
tablet 153 mg 120 mg tablet (Art) 50 mg
base
Day 1 2 3 Day 1 2 3
5-7 yr 1+1 2 SP 1 Art 1 1 1
(19-24 kg) Art 1 1 1 Mef 1
8-13 yr or small 2+2 3 SP 2 Art 2 2 2
or wasted adult Art 2 2 2 Mef 2 1
(25-50 kg)
14 yr + (>50 kg) 4+4 4 SP 3 Art 4 4 4
Art 4 4 4 Mef 4 2

* The second dose on the first day should be given any time between 8h and 12h after the first dose.
Dosage on the second and third days is twice a day (morning and evening)
** Do not use sulfadoxine/pyrimethamine for treatment if patient is on cotrimoxazole prophylaxis.
For children under 5 years, see IMCI guidelines.

Give paracetamol for pain


❖ Give every 6 hours (or every 4 hours if severe pain).
❖ Do not exceed 8 tablets (4 gms) in 24 hours. If pain not controlled
with paracetamol, alternate aspirin with paracetamol. If pain is
chronic, see Palliative Care module P8. If severe acute pain, see
Quick Check module.
Adolescent or Adult paracetamol 500 mg tablet
40-50 kg or more 1 tablet
50 kg or more 1-2 tablets

Do not use for > 1 week if on nevirapine.

80
Give albendazole or mebendazole
albendazole 400 mg single dose OR
mebendazole 500 mg single dose

Give prednisolone
❖ For acute moderate or severe wheezing, before referral:
Give prednisolone or prednisone 60 mg orally.
Or, if not able to take oral medication, give either:
- hydrocortisone 300 mg IV or IM, or
- methyprednisolone 60 mg IV/IM.
❖ For asthma or COPD not under control, where prednisone is in
the treatment plan, give prednisolone or prednisone.
Give high dose for several days, then taper, and then stop.
COPD may require longer treatment at low level. (See Practical
Approach to Lung Health—PAL Guidelines.)

prednisolone or prednisone 5 mg tablets


Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
ADULT 7 7 7 6 5 4 3

81
Give amitriptyline
Useful for depression, insomnia and for some neuropathic pain. Helps
relieve pain when used with opioids and for sleep, in a low dose.

❖ For depression:
Educate about the drug (the patient and family):
• Not addictive.
• Do not use with alcohol.
• Takes 3 weeks to get a response in depression—don’t be
discouraged; often see effect on sleep or pain within 2-3 days.
• May feel worse initially. Side effects (dry mouth, constipation,
difficulty urinating and dizziness) usually fade in 7-10 days.
• Will need to continue for 6 months. Do not stop abruptly.
• If suicide risk, give only one week supply at time or have caregiver
dispense drug.
• May impair ability to perform skilled tasks such as driving—take
precautions until used to drug.
• For elderly or HIV patients, warn to stand up slowly (risk of
orthostatic hypotension).
• HIV clinical stage 3 or 4 patients are very sensitive to side effects of
amitriptyline.
Weight Starting dose After 1 After 2 weeks, 2 weeks later
week, increase to: if inadequate
increase to: response
< 40 kg 0.5-1 mg/kg
40 kg or 50 mg pm 75 mg pm 25 mg am 50 mg am
more 75 mg pm 100 mg pm

Elderly or 25 mg pm 25 mg am 25 mg am
HIV stage 3 50 mg pm 50 mg pm
or 4 patient

❖ For painful foot/leg neuropathy:


Low-dose amitriptyline—25 mg at night or 12.5 mg twice daily. (Some
experts advise starting as low as 12.5 mg daily.) Wait 2 weeks for
response, then increase gradually to 50 mg.

❖ For problems with sleep:


Use low dose at night—12.5 to 25 mg.

82
Give haloperidol

Indications:
psychosis, acute severe agitation, or danger to self or others.
Make sure any underlying medical condition is also treated.
❖ If medically healthy:
haloperidol 5 mg once or twice daily.
❖ If medically ill, elderly or HIV clinical stage 3 or 4:
haloperidol 0.5 to 1 mg once or twice daily (orally or IM).
❖ In uncontrollable HIV clinical stage 3 or 4 patient:
haloperidol 2 mg and, if no response in one hour, add
haloperidol 2 mg.
Then, if still not adequately sedated, add diazepam 2 to 5 mg orally.
Side effect of halperidol: stiffness, tremor, muscle spasm and motor
restlessness. (HIV positive patients are especially sensitive to the
side-effects of halperidol.)
If acute severe muscle spasm, especially of the mouth, neck or eyes:
• Maintain airway.
• Stop haloperidol.
• Give diazepam 5 mg rectally.
• Refer.
• If available, give biperiden 5 mg IM.

83
Treat with nystatin

❖ Treat oral thrush with nystatin:


• Suck on nystatin uncoated lozenges twice daily or apply nystatin
suspension five times daily (after each meal and between meals)
for seven days (or until 48 hours after lesions resolve).
❖ Treat candida vaginitis with nystatin pessaries:
• Dosage: 100 000 IU daily by vaginal pessaries.
• Dispense 14 nystatin suppositories.

If relapse—treat first week of every month or when needed (consider


HIV-related illness and diabetes).

Treat with antiseptic

❖ Wash hands before and after each treatment.


To treat impetigo or herpes zoster with local bacterial infection:
• Gently wash with soap and water.
• Paint with topical antiseptic. Choices include:
- chlorhexidine
- polyvidone iodine
- full-strength gentian violet (0.5%)
- brilliant green
• Keep skin clean by washing frequently and drying after washing.

84
Give aciclovir

❖ Primary infection:
200 mg five times daily for seven days or
400 mg three times daily for seven days.
❖ Recurrent infection:
As above except for five days only.

Give fluconazole

❖ For suspected oesophageal candidiasis:


400 mg in clinic, then 200 mg per day for 14 days. If no response in
3-5 days, increase to 400 mg per day.

Give ketoconazole

❖ For resistant oral thrush or vaginal candidiasis, give ketoconazole


200 mg daily.

Apply podophyllin (do not use in pregnancy or children)

❖ By health worker—10-20% in compound tincture of benzoin.


Apply weekly.
Apply only to warts—avoid and protect normal tissue. Let dry.
Wash thoroughly 1-4 hours after application.
❖ By patient—only if Podofilox or Imiquimod are available.

85
Treat scabies

Treat with one of the Treatment period Warnings


following: For all treatments—will
initially itch more (as
mites die and lead to
inflammatory response)
then itch goes away.
1% Lindane (gamma once—wash off after 24 potentially toxic if overused;
benzene hexachloride) hours (after 12 hours in avoid in pregnancy and
cream or lotion children) small children
25% benzyl benzoate at night, wash off in tendency to irritate the skin
emulsion—dilute 1:1 for morning–repeat if
children; 1:3 for infants necessary
5% permethrin cream expensive, very low systemic
absorption and toxicity

❖ Patient and all close contacts must be treated simultaneously—whole


household and sexual partners, even if asymptomatic.
❖ Clothing or bed linen that have possibly been contaminated by the
patient in the two days prior to the start of treatment should be
washed and dried well (or dry-cleaned).
❖ Do not bathe before applying the treatment (increases systemic
absorption and does not help).
❖ Apply the cream to the whole skin surface giving particular attention
to the flexures, genitalia, natal cleft, between the fingers and under
the fingernails. Include the face, neck and scalp but avoid near the
eyes and mouth.
❖ The cream may irritate the skin a little, especially if there are
excoriations.
❖ Keep on for the treatment period.
❖ If any cream is washed off during the treatment period (e.g., hands)
reapply immediately.
❖ Wash the cream off at the end of the treatment period.
❖ Itching should start to diminish within a few days, but may persist for
a number of weeks. This does not mean that the treatment has failed.
Another cream may help with the itching (crotamiton or topical
steroid).

86
Advise on symptom control for cough/cold/bronchitis

❖ Advise to use a safe, soothing remedy for cough


• Safe remedies to recommend:

• Harmful remedies to discourage (health worker should add local


harmful remedies):

❖ If running nose interferes with work: suggest decongestant

❖ For fever, give paracetamol (p. 80)

Give iron/folate
❖ For anaemia: 1 tablet twice daily iron/folate tablets:
iron 60 mg, folic acid
400 microgram

87
Dehydration
Plan A for adolescents/adults: treat diarrhoea at
home.
❖ Counsel the patient on the 3 Rules of Home Treatment: Drink
extra fluid, continue eating, when to return.
1. Drink extra fluid (as much as the patient will take)—any fluid
(except fluids with high sugar or alcohol) or ORS.
• Drink at least 200-300 ml in addition to usual fluid intake after
each loose stool.
• If vomiting, continue to take small sips. Antiemetics are usually
not necessary.
• Continue drinking extra fluid until the diarrhoea stops.
- It is especially important to provide ORS for use at
home when:
-- the patient has been treated with Plan B or Plan C
during this visit;
-- the patient cannot return to a clinic if the diarrhoea
gets worse; or
-- the patient has persistent diarrhoea or large volume
stools.
IF ORS is provided: TEACH THE PATIENT HOW TO MIX AND DRINK ORS.
GIVE 2 PACKETS OF ORS TO USE AT HOME.

2. Continue eating.
3. When to return.

88
Plan B for adolescents/adults: treat some
dehydration with ORS

❖ Give in clinic recommended amount of ORS over 4 hour period.


• Determine amount of ORS to give during first 4 hours.
* Use the patient’s age only when you do not know the weight. The approximate
amount of ORS required (in ml) can also be calculated by multiplying the patient’s
weight (in kg) times 75.
- If the patient wants more ORS than shown, give more.

AGE * 5-14 years ≤15 years


WEIGHT 20 < 30 kg 30 kg or more
In ml 1000-2200 2200-4000

• If the patient is weak, help him/her take the ORS:


- Give frequent small sips from a cup.
- If the patient vomits, wait 10 minutes. Then continue, but more slowly.
- If patient wants more ORS than shown, give more.
• After four hours:
- Reassess the patient and classify for dehydration.
- Select the appropriate plan to continue treatment.
- Begin feeding the patient in clinic.
• If the patient must leave before completing treatment:
- Show how to prepare ORS solution at home.
- Show how much ORS to give to finish four-hour treatment at home.
- Give enough ORS packets to complete rehydration. Also give two
packets as recommended in Plan A.
- Explain the 3 Rules of Home Treatment: See Plan A for
recommended fluids
1. Drink extra fluid
2. Continue eating
3. When to return

89
Plan C: Treat severe dehydration quickly—at any age

❖ FOLLOW THE ARROWS. IF ANSWER IS “YES”, GO ACROSS.


IF “NO”, GO DOWN.

START HERE

Can you give


intravenous (IV) YES
fluid immediately?

NO

Is IV treatment
available nearby YES
(within 30 minutes)?

NO

Are you trained to


use a naso-gastric
(NG) tube for
rehydration?

NO

Can the patient


} YES

drink?

NO

Refer URGENTLY to
hospital for IV or NG
treatment.

90
• Start IV fluid immediately. If the patient can drink, give ORS by mouth while the drip
is set up. Give 100 ml/kg Ringer’s Lactate Solution (or, if not available, normal saline),
divided as follows:

Age First give 30 ml/kg in: Then give 70 ml/kg:


Infants (under 12 1 hour * 5 hours
months)
Older (12 months or 30 minutes * 2 ½ hours
older, including adults)
∗ Repeat once if radial pulse is very weak or not detectable.

• Reassess the patient every 1-2 hours. If hydration status is not improving, give the IV
drip more rapidly.
• Also give ORS (about 5 ml/kg/hour) as soon as the patient can drink: usually after
3-4 hours (infants) or 1-2 hours for children, adolescents and adults.
• Reassess an infant after 6 hours and older patient after 3 hours. Classify dehydration.
Then choose the appropriate plan (A, B, or C) to continue treatment.

• Refer URGENTLY to hospital for IV treatment.


• If the patient can drink, provide the mother or family/friend with ORS solution and
show how to give frequent sips during the trip.

• Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg/hour for six
hours (total of 120 ml/kg).
• Reassess the patient every 1-2 hours:
- If there is repeated vomiting or increasing abdominal distension, give the fluid
more slowly.
- If hydration status is not improving after 3 hours, send the patient for IV therapy.
• After six hours, reassess the patient. Classify dehydration. Then choose the
appropriate plan (A, B, or C) to continue treatment.

NOTE: If possible, observe the child at least 6 hours after rehydration to be sure the
mother can maintain hydration giving the child ORS solution by mouth.

91
Refer urgently to hospital *

❖ Discuss decision with patient and relatives.


❖ Quickly organize transport.
❖ Send with patient:
• Health worker, if airway problem or shock.
• Relatives who can donate blood.
• Referral note.
• Essential emergency supplies (below).
❖ Warn the referral centre by radio or phone, if possible.
❖ During transport:
• Watch IV infusion.
• Keep record of all IV fluids, medications given and time of
administration.
• If transport takes more than four hours, insert Foley catheter to
empty bladder; monitor urine output.

* If referral is difficult and is refused: Adapt locally

* If chronic illness, determine if palliative care is preferred.


Does patient have known terminal disease in a late stage
(AIDS without ART, COPD, lung cancer, etc)?
Discuss needs with family and patient—can these be better met at
home, with support? Comfort of the patient is prime responsibility.

92
Essential Emergency Supplies To Have
During Transport
Emergency Drugs Quantity for Transport
• Diazepam (parenteral) 30 mg
• Artemether or 160 mg (2 ml)
• Quinine 300 mg
• Ampicillin 2 grams
• Gentamicin 240 mg
• IV glucose—50% solution 50 ml
• Ringer’s lactate 4 litres
(take extra if distant referral)

Emergency Supplies Quantity for Transport

IV catheters and tubing 2 sets

Clean dressings

Gloves, one of which is sterile at least 2 pairs

Clean towels 3

Sterile syringes and needles

Urinary catheter

93
94
Advise and Counsel

Advise and Counsel

95
❖ Preamble

These guidelines are in accordance with the


June 2004 WHO/UNAIDS Policy Statement
on HIV Testing which calls for the standard
pre-test counseling used in VCT services
to be adapted in provider-initiated testing
and counselling to simply provide pre-test
education and ensure informed consent,
without a counselling session. The minimum
amount of information that patients require
in order to be able to provide informed
consent is outlined below. This is for country
adaptation.

96
Advise and Counsel

Provide key information on HIV (Human Immune


Deficiency Virus)

❖ Counsel on how HIV is transmitted and not transmitted

HIV is a virus that destroys parts of the body’s immune system. A


person infected with HIV may not feel sick at first, but slowly the
body’s immune system is destroyed. S/he becomes ill and is unable
to fight infection. Once a person is infected with HIV, s/he can
transmit the virus to others.

HIV can be transmitted through:


• Exchange of HIV-infected body fluids such as semen, vaginal fluid
or blood during unprotected sexual intercourse.
• HIV-infected blood transfusions.
• Injecting drug use.
• Sharing of instruments for tattoo or skin piercing.
• From an infected mother to her child during:
- pregnancy;
- labour and delivery; and
- postpartum through breastfeeding

HIV cannot be transmitted through hugging or kissing, or mosquito


bites.

A special blood test is done to find out if the person is infected


with HIV.

97
HIV Testing and Counselling

❖ A provider-initiated HIV test and counselling session


is composed of three steps:

1 Pre-test information and education (see p. 100)

2 HIV testing. (see p. 120)

3 Post-test counselling. (see p. 103)

When and how to offer


❖ An HIV test and counselling session should be
offered:
• whenever a patient presents with signs or
symptoms consistent with HIV infection, or
• whenever a sexually active individual of unknown
serostatus can benefit from an HIV test and
counselling.

❖ In a clinical context, there are two situations in


which an HIV test will be offered:
• Diagnostic testing as part of a health worker’s
workup for a diagnosis of a sick patient
• Routine offer for a patient accessing the clinic for
other, non-HIV related services (antenatal care,
other illnesses, family planning, STI, etc.)

❖ In both situations, the patient should be offered the


opportunity to refuse or “opt-out” of the test.

98
Diagnostic testing
❖ Diagnostic testing is part of the clinical process of determining the
diagnosis of a sick patient. If the patient presents with symptoms
consistent with HIV infection, explain that you will be testing for the
HIV virus as part of your clinical workup.

❖ Diagnostic HIV testing should be offered in this way for all the
conditions in Acute Care where the treatment column indicates
“Consider HIV-related illness.” These are summarized on p. 54.

❖ For example: “You are sick; I want to find out why. In order for us to
diagnose and then treat your illness, you need tests for typhoid, TB and
HIV infection. Unless you object, I will conduct these tests.”

Routine offer

❖ Routine offer of testing and counselling means offering an HIV


test to all sexually active patients who present for medical care
regardless of their initial reason for seeking medical attention.

❖ For example: “One of our hospital policies is to provide everyone with


the opportunity to have an HIV test so that we can provide you with
care and treatment while you are here and refer you for follow-up after
discharge. Unless you object, I will conduct this test and provide you
with counselling and the results.”

❖ In both diagnostic testing and routine offer


the patient should be provided with the following
pre-test information.

❖ This information can be delivered either individually


by a health care worker, including a social worker,
or through group pre-test information sessions.

99
Pre-test information and education to an adult*

❖ Pre-test information may be given by a physician, nurse or ART


Aid or other counsellor. Pre-test information can be given to
an individual or to a group of patients.

❖ Pre-test information should focus on three main components

1. Provide key information on HIV/AIDS

2. Explain procedures to safeguard confidentiality

3. Confirm willingness of patient to proceed with test and seek


informed consent. Additional information should be provided as
necessary with referral for additional counselling, as needed.

1. Provide key information on HIV

Say: “HIV is a virus or a germ that destroys the part of your body
needed to defend a person from illness. The HIV test will determine
whether you have been infected with the HIV virus. It is a simple blood
test that will allow us to make a clearer diagnosis.

Following the test, we will be providing counselling services to talk


more in-depth about HIV AIDS.

If your test result is positive, we will provide you with information and
services to manage your disease. This may include antiretroviral drugs
and other medicines to manage the disease. In addition, we will help
you with support for prevention and for disclosure.

If it is negative, we will focus on ensuring you have access to services


and commodities to help you remain negative.”

* For adolescent, see Adolescent Job Aid

100
2. Explain procedures to safeguard confidentiality

Say: “The results of your HIV test will only be known to you and the
medical team that will be treating you. This means the test results are
confidential and it is against our facility’s policy to share the results
with anyone else, without your permission. It is your decision to tell
other people the results of this test.”

3. Confirm willingness of patient to proceed with test and seek


informed consent
Informed consent means that the individual has been provided
essential information about HIV/AIDS and HIV testing, has fully
understood it and based on this has agreed to undergo an HIV test.
• Unless you object, I will get a sample for HIV testing. I think it
will be important for you to know this information.
OR
• I want to perform an HIV test today. If that isn’t all right, you
need to let me know.
OR
• I think this test will help me take care of your health and,
unless you object, I’m going to obtain a sample. Can you agree
with me?
If the patient has additional questions, provide additional
information (next page). If the patient is unsure about or
uncomfortable with proceeding with the HIV test or declines the
test, refer him/her to the facility-based counsellor for a full pre-test
counselling session. This session should address barriers to testing
and re-offer the test.
If the patient is ready, then seek oral consent: “In order to carry out
this test, we need your consent.”
Remember: It is the patient’s right to refuse an HIV test. HIV testing
is never mandatory.

101
❖ If patient requires additional information, discuss advantages
and importance of knowing HIV status.
Things to say:
• The testing will allow health care providers to make a proper
diagnosis and ensure effective follow-up treatment.
• If you test negative, we can eliminate HIV infection from our
diagnosis and provide counselling to help you remain negative.
• If you test positive, you will be supported to protect yourself
from reinfection and your partner from infection.
• You will be provided with treatment and care for managing your
disease, including:
- cotrimoxazole prophylaxis;
- regular follow-up and support:
- treatment for infections; and
- ARV therapy. (Explain availability and when it is used. See
Chronic HIV Care module.)
• You will be supported to access interventions to prevent
transmission from mothers to their infants, and make informed
decisions about future pregnancies.
• We will also discuss the psychological and emotional
implications of HIV infection with you and support you to
disclose your infection to those you decide need to know.
• An early diagnosis will help you cope better with the disease
and plan better for the future.

102
Post-test counselling
❖ If test result is positive and has been confirmed:
• Explain that a positive test result means that s/he has the infection.
• Give post-test counselling and provide support (p. H50).
• Offer ongoing care (see Chronic HIV Care module) and arrange for
a follow-up visit.
• Advise that it is especially important to practice safer sex–.to avoid
infecting others, to avoid other sexually transmitted infections and
to avoid getting a second strain of HIV. Create a risk reduction plan
with patient
• Advise adult men to avoid sex with teenagers outside marriage, to
avoid spreading the infection to the next generation.
• Refer, as needed, patient for additional prevention and/or
care services, including peer support, and special services for
vulnerable populations.

❖ If test result is negative:


• Share relief or other reactions with the patient.
• Counsel on the importance of staying negative by correct and
consistent use of condoms, and other practices to make sex safer.
Create a risk reduction plan with patient.
• If recent exposure or high risk, explain that a negative result can
mean either that s/he is not infected with HIV, or is infected with
HIV but has not yet made antibodies against the virus. (This is
sometimes called the "window" period—3 to 6 months.) Repeat
HIV testing can be offered after 8 weeks.
• Refer, as needed, patient for additional prevention and/or
care services, including peer support, and special services for
vulnerable populations.

❖ If the patient has not been tested, has been tested but does not
want to know results or does not disclose the result:
• Explain the procedures to keep the results confidential.
• Reinforce the importance of testing and the benefits of knowing
the result.
• Explore barriers to testing, to knowing, and to disclosure (fears,
misperceptions, etc.).

103
Support disclosure
• Discuss advantages of disclosure.
• Ask the patient if they have disclosed their result or are willing to disclose the
result to anyone.
• Discuss concerns about disclosure to partner, children and other family, friends.
• Assess readiness to disclose HIV status and to whom. (Start with least risky.)
Assess social network.
• Assess social support and needs. (Refer to support groups.) See Chronic HIV
Care Annex A.4.
• Provide skills for disclosure. (Role play and rehearsal can help.)
• Help the patient make a plan for disclosure.
• Encourage attendance of the partner to consider testing; explore barriers to this.
• Reassure that you will keep the result confidential.
• If domestic violence is a risk, create a plan for a safe environment.

❖ If the patient does not want to disclose the result:


• Reassure that the results will remain confidential.
• Explore the difficulties and barriers to disclosure. Address fears and lack of skills.
(Help provide skills.)
• Continue to motivate. Address the possibility of harm to others.
• Offer another appointment and more help as needed (such as peer counsellors).

❖ Especially for women, discuss benefits and possible disadvantages of


disclosure of a positive result, and involving and testing partners.

Men are generally the decision makers in the family and communities.
Involving them will:
• Have greater impact on increasing acceptance of condom use and
practicing safer sex to avoid infection.
• Help avoid unwanted pregnancy.
• Help to decrease the risk of suspicion and violence.
• Help to increase support to their partners.
• Motivate them to get tested.

Disadvantages of involving and testing the partner: danger of blame, violence


and abandonment.

Health worker should try to counsel couples together, when possible.

104
Counsel on safer sex and condom use

❖ Safer sex is any sexual practice that reduces the risk of


transmitting HIV and other sexually transmitted infections (STIs)
from one person to another.
• Protection can be obtained by:
- Correct and consistent use of condoms; condoms must be used
before any penetrative sex, not just before ejaculation.
- Abstaining from sexual activity.
- Choosing sexual activities that do not allow semen, fluid from
the vagina or blood to enter the mouth, anus or vagina of the
partner, and not touching the skin of the partner where there is
an open cut or sore.

❖ If HIV positive:
• Explain to the patient that s/he is infected and can transmit
infection to the partner. A condom should be used, as above.
• If partner’s status is unknown, counsel on benefits of involving
and testing the partner (p. 101).
• For women: explain the extra importance of avoiding infection
during pregnancy and breastfeeding. The risk of infecting the
baby is higher if the mother is newly infected.

❖ If HIV negative OR result is unknown:


• Discuss the risk of HIV infection and how to avoid it.
• If partner’s status is unknown, counsel on benefits of testing the
partner.
• For women: explain the extra importance of remaining negative
during pregnancy and breastfeeding. The risk of infecting the
baby is higher if the mother is newly infected during this time.

Make sure the patient knows how to use condoms and where to get
them. Provide easy access to condoms in clinic in a discrete manner.

Ask: Will you be able to use condoms? Check for barriers.

105
Educate and counsel on STIs

❖ Speak in private, with enough time, and assure confidentiality.


❖ Explain:
• The disease. Special counselling for
adolescents:
• How it is acquired. See Adolescent Job Aid.
• How it can be prevented.
• The treatment.
• That most STIs can be cured, except HIV, herpes and
genital warts.
• The need also to treat the partners (except for vaginitis):
- Recent sex partner(s) are likely to be infected but may be
unaware.
- If partners are untreated, they may develop complications.
- Sex with untreated partners can lead to re-infection.
- Treatment of the partner, even if no symptoms, is important to
the health of the partner and to you.
❖ Listen to the patient: is there stress or anxiety related to STIs?
❖ Promote safer sexual behaviour to prevent HIV and STIs.
• Counsel on limiting partners (or abstinence) and careful
selection of partners.
Refer for counselling on:
• Instruct in condom use (p. 102). • Concerns about herpes infection
(no cure).
❖ Educate on HIV.
• Possible infertility related to PID.
❖ Advise HIV testing and counselling • Behavioural-risk assessment.
(p. 98). • Patient with multiple partners.
• Difficult circumstances or risk.
❖ Inform the partner(s) or spouse.
• Ask the patient, can you do this? Ask, is it possible for you to:
- Talk with your partner about the infection?
- Convince your partner to get treatment?
- Bring/send your partner to the health centre?
• Determine your role as the health worker.
• Strategies to discuss and introduce condom use.
• Risk of violence or stigmatizing reactions from partners and
family.

106
Basic counselling

All providers can apply counselling skills in a range of clinical situations.


These include:
❖ Educating patients
❖ Providing emotional support
❖ Supporting patients with mental illness such as depression
or anxiety disorders
❖ Addressing multiple aspects of HIV care (HIV testing, disclosure
of HIV status, safer sex and condom use, adherence to care
and treatment)
❖ Intervening in a crisis situation

Elements of basic counselling


❖ Establish a good relationship.
❖ Find out (what) the patient’s current situation (is).
❖ Respond with empathy.
❖ Provide feedback that enables the patient to make sense of the
situation.
❖ Offer information.
❖ Help the patient recognize his/her strengths.
❖ Help the patient identify and find ways to connect with family or
friends who can provide support.
❖ Teach specific skills that help patients deal with their situation:
Relaxation techniques such as deep breathing or progressive
muscular relaxation or positive imagery.
Problem solving.
❖ Provide encouragement.
❖ Convey hope.

107
Useful tools for counselling:
❖ Use more open-ended than closed questions.
• Open-ended question: What problems have you had recently
in taking your medicines?
• Closed question: Did you take your medicine today?
❖ Listen carefully, paying attention to verbal and non-verbal
communication.
❖ Clarify responses that you do not understand.
❖ Use role-playing to help the patient develop skills and
confidence to carry out a plan.
❖ Allow time for questions from the patient.
❖ Ask about suicidal thoughts (in the case of crises and
mental illness).

The counsellor’s role:


❖ Provide confidentiality.
❖ Provide support.
❖ Help the patient prioritize problems and find own solutions.
❖ Be aware of the patient’s treatment.
❖ Be aware of other referral resources.
❖ Be aware of the patient’s social-support resources.
❖ Advocate for the patient.
❖ Refer to treatment, care and prevention services, as appropriate.

When working with patients:


❖ Ensure privacy.
❖ Minimize interruptions.
❖ Ensure patient’s comfort.
❖ Agree on the length of time you have.
❖ Make arrangements for follow-up when necessary.

108
Counsel the depressed patient and family

❖ Review the symptoms of depression that the patient is experiencing.


(See p. 50-51).

❖ Give essential information.


• Explain that the symptoms are part of the illness called
depression.
• Depression is common and effective treatment is available.
• Depression is not a sign of weakness or laziness.
• The patient is trying hard to manage.

❖ Recognize the distress of the patient by saying that you understand


how badly s/he feels and that you want to be of some assistance
to him/her.

❖ Inquire of the patient how depressed s/he feels at the moment


compared to how s/he has been feeling, in order to inform your
treatment plan.

❖ Ask if s/he has thought about hurting themselves or if s/he is


thinking much about death.

If risk of suicide and harm to others, see Quick Check guidelines.

❖ Plan short-term activities which give the patient enjoyment or


build confidence.

❖ Identify current life problems or social stresses. Focus on small,


specific steps the patient might take towards managing these
problems.
• If bereavement after a death, see Palliative Care module, p. 48.
• If HIV+, give support. See Chronic HIV Care module, Annex A.
• If new TB diagnosis and worried about HIV, give support.
• Teach new problem-solving techniques.

109
❖ Encourage patient to resist pessimism and self-criticism:
• Not to act on pessimistic ideas (end marriage, leave job).
• Not to concentrate on negative or guilty thoughts.

❖ If counselling is not sufficiently helpful, consider these additional


interventions:

• Give amitriptyline, especially if sleep and appetite


are significantly disturbed (p. 82).
_ If already on anti-depressant, check on adherence and dose.
The dose may need to be raised.
_ Remind patient that it takes 2-3 weeks for the medication
to work.
_ After improvement, discuss action to be taken if signs of
depression return.
• Refer to support group.
• Refer to skilled counsellor.
• If suicide risk or major depression not responding to treatment,
consult or refer.

110
Laboratory Tests

111
Collect sputum for examination for TB
❖ Explain that the TB suspect needs a sputum examination to determine
whether there are TB bacilli in the lungs.

❖ List the TB suspect’s name and address in the Register of TB Suspects.

❖ Label sputum containers (not the lids).


TB SPECIMEN
• Three samples are needed for Name: ______________________
diagnosis of TB. Health facility: ________________
Date: _______________________
• Two samples are needed for
Specimen no. ________________
follow-up examination.

❖ Fill out Request for Sputum


Examination form.

❖ Explain and demonstrate, fully and slowly, the steps to collect


sputum.
• Show the TB suspect how to open and close the container.
• Breathe deeply and demonstrate a deep cough.
• The TB suspect must produce sputum, not only saliva.
• Explain that the TB suspect should cough deeply to produce
sputum and spit it carefully into the container.

❖ Collect
• Give the TB suspect the container and lid.
• Send the TB suspect outside to collect the sample in the open air, if
possible, or to a well-ventilated place with sufficient privacy.
• When the TB suspect returns with the sputum sample, look at it. Is
there a sufficient quantity of sputum (not just saliva)? If not, ask the
TB suspect to add some more.
• Explain when the TB suspect should collect the next sample, if
needed.

112
Schedule for collecting three sputum samples

Day One:
• Collect "on-the-spot" sample as instructed above (Sample 1).
• Instruct the TB suspect how to collect an early-morning sample
tomorrow (first sputum after waking). Give the TB suspect a labelled
container to take home. Ask the TB suspect to bring the sample to the
health facility tomorrow.

Day Two:
• Receive early-morning sample from the TB suspect (Sample Two).
• Collect another "on-the-spot" sample (Sample Three).

❖ When you collect the third sample, tell the TB suspect when to
return for the results.

❖ Store
• Check that the lid is tight.
• Isolate each sputum container in its own plastic bag, if possible, or
wrap in newspaper.
• Store in a cool place.
• Wash your hands.

❖ Send
• Send the samples from health facility to the laboratory.
(See page 113.)

113
114
Year _______________ Facility ______________________
REGISTER OF TB SUSPECTS

Age Date Results of TB Treatment


Date Sputum Observations/
TB Suspect Sputum Card
Date Name of TB Suspect Complete Address Results Examinations Clinician’s
Number Sent to Opened?
Received Diagnosis
M F Lab 1 2 3 (record date)

If negative,
record “Neg.”
If positive,
record the grade
(+, ++, +++).
When a result is
“scanty,” record
the number.

2
Send sputum samples to laboratory
❖ Keep the samples in a refrigerator, or in a place as cool as possible until
transport.

❖ When you have all 3 samples, pack the sputum containers in a transport
box. Enclose the Request for Sputum Examination. (See next page.) If
there are samples for more than 1 patient, enclose a Request for Sputum
Examination for each patient’s samples.

❖ If a patient does not return to the health facility with the second sample
within 48 hours, send the first sample to the laboratory anyway.

❖ Send the samples to the laboratory as soon as possible. Do not hold


for longer than 3–4 days. The total time from collection until reaching
the laboratory should be no more than 5 days. Sputum samples should
be examined by microscopy no later than 1 week after they have been
collected.

❖ Prepare a dispatch list to accompany each transport box. (See example


below.) The dispatch list should identify the sputum samples in the box.
Before sending the box to the laboratory:
• Check that the dispatch list states:
• the correct total number of sputum containers in the box;
• the identification numbers on the containers; and
• the name of each patient.
• Check that a Request for Sputum Examination is enclosed for each
patient.
• Close the box carefully.
• Write the date on the dispatch list.

Put the dispatch list in an envelope and attach envelope to the outside of
the transport box.

115
TB LABORATORY FORM
REQUEST FOR SPUTUM EXAMINATION

Name of health facility __________________________ Date _________________


Name of patient ______________________________ Age ______ Sex: M p F p
Complete address __________________________________________________________
_______________________________ District _______________

Reason for examination:


Diagnosis p TB Suspect No. ______________
OR Follow-up p Patient’s District TB No.* _____________

Disease site: Pulmonary p Extrapulmonary p (specify)_______________


Number of sputum samples sent with this form _____
Date of collection of first sample ____________ Signature of specimen collector ________

* Be sure to enter the patient’s District TB No. for follow-up of patients on TB treatment.

RESULTS (to be completed by Laboratory)


Lab. Serial No. ____________________________
(a) Visual appearance of sputum:
Mucopurulent Blood-stained Saliva

(b) Microscopy:
DATE SPECIMEN RESULTS POSITIVE (GRADING)
+++ ++ + scanty (1–9)
1

Date _______ Examined by (Signature) __________________________________

The completed form (with results) should be sent to the health facility and to the District
Tuberculosis Unit.

116
Instructions for some lab tests which can be performed
in clinic:
❖ Haemoglobin
Insert local method.

❖ Urine dipstick for sugar or protein:


• Follow instructions from test package.

❖ Blood sugar by dipstick

❖ Malaria dipstick
• Insert instructions from test package.

❖ Malaria smear (thick film):


• Prepare a thick film (so that printed letters can’t be read through it).
• Air dry.
• Cover with diluted Leishman stain (1:3) for 7 mins
OR cover with diluted Giemsa (1:10) for 15 mins
OR dip for two seconds in Field stain A and wash with water, and then two
seconds in Field stain B and wash in water.
• Allow to dry.
• Examine a minimum of 100 fields under X100.
Result: look for red chromatin dot, blue cytoplasm.
Note:
If the film is positive, do a thin film to identify the species.
When dealing with Plasmodium falciparum do an exact parasite count.
Grading:
Parasite count: Grade:
1 to 10 malaria parasites per 100 fields +
10 to 100 malaria parasites per field ++
1 to 10 parasites per field +++
10 to 100 parasites per field ++++

117
Perform RPR (Rapid Plasma Reagin) test for syphilis
and respond to result

❖ Have patient sit comfortably on chair. Explain procedure and obtain consent.
Put on gloves.
❖ Use a sterile needle and syringe. Draw up 5 ml blood from a vein. Put in a plain
test tube.
❖ Let test tube sit 20 minutes to allow serum to separate. (Or centrifuge 3-5
minutes at 2000-3000 rpm.) In the separated sample, serum will be on top.
❖ Use sampling pipette to withdraw some of the serum. Take care not to include
any red blood cells from the lower part of the separated sample.
❖ Hold the pipette vertically over a test-card circle. Squeeze teat to allow one
drop (50 ml) of serum to fall onto a circle. Spread the drop to fill the circle using
a toothpick or other clean spreader.
Important: Several samples may be done on 1 test card. Be careful not to
contaminate the remaining test circles. Use a clean spreader for each sample.
Carefully label each sample with a patient name or number.
❖ Attach dispensing needle to a syringe. Shake antigen.* Draw up enough
antigen for the number of tests done (one drop per test).
❖ Holding the syringe vertically, allow exactly one drop of antigen to fall onto
each test sample. Do not stir.
❖ Rotate the test card smoothly on the palm of the hand for 8 minutes. **
(Or rotate on a mechanical rotator.)

INTERPRETING RESULTS
❖ After 8 minutes rotation, inspect the card in good light. Turn or tilt the card
to see whether there is clumping (reactive result). Most test cards include
negative and positive control circles for comparison.
1. Non-reactive (no clumping or only slight
Example Test Card roughness)—negative for syphilis
2. Reactive (highly visible clumping)—
positive for syphilis
3. Weakly reactive (minimal clumping)—
positive for syphilis
NOTE: Weakly reactive can also be more
finely granulated and difficult to see than in
this illustration.
* Make sure antigen was refrigerated (not frozen) and has not expired.
** Room temperature should be 73º - 85ºF (22.8º - 29.3ºC).

118
Assure confidentiality in performing the RPR test

If RPR positive:

❖ Determine if the patient and partner have received adequate


treatment.

❖ If not, treat patient and partner for syphilis with benzathine


penicillin (p. 69).
• If patient has just delivered, treat newborn with benzathine
penicillin.
• Follow up on newborn in 2 weeks.

❖ Counsel on safer sex. Advise to use condoms.

Note: Do not test for cure with a repeat RPR.


The RPR remains positive for some time although the titer goes down.

119
Perform rapid HIV test, interpret results, then counsel
The following strategy is proposed for countries with HIV prevalence
of greater than 5%. If HIV prevalence is less than 5%, refer to the IMAI
Country Adaptation Guide.

All countries should adapt the strategy to reflect national HIV testing
and counselling guidelines (including HIV test kits and their validation).

❖ Collection of blood from a finger tip


• Always use gloves to take or transfer blood.
• Rub the finger tip warm to get the blood circulating
(index, middle or ring finger).
• Clean the finger with alcohol and allow to air dry.
• Hold finger lower than elbow.
• Prick the finger with a clean and sterile unused lancet.
• Collect sample of blood as per test instructions (e.g. use
pipette for Uni-Gold HIV™ and sample loop for Stat-Pak™).
• Dispose the used lancet in a biohazardous
safe container. How to prick a
finger tip.
• Complete the specific test procedure.
• Disinfect finger and cover with a plaster.
• Follow universal safety precautions for waste
disposal. The preferred methods are autoclaving
at 120ºC for 60 minutes or by incineration.
❖ Test kits
• You should have at least two different test kits available.
• Only use test kits and testing algorithms as recommended by the
national and/or international bodies.
• Respect expiry dates—kits that have expired should not be used.
• Strictly follow storage procedures.
• If kits have been stored at 2–8ºC, allow kits to reach room
temperature by removing them from the refrigerator
approximately 20 minutes before using them.
120
• Validate your test kit using the manufacturer’s directions and the
positive and negative controls provided. If possible run the controls
for each new operator, new test batch or if you are concerned with
storage conditions.
• Strictly follow testing procedures.
• Very strictly respect the recommended reading time.
• Always label specimens and/or test devices clearly.
• Prepare worksheet in which specimen numbers are clearly written
and results are immediately recorded.
❖ Test kit preparation (applicable to all test kits)
• If refrigerated, remove test kit from refrigerator and allow to stand
for at least 20 minutes to reach room temperature (20–25ºC).
• Prepare your worksheet, indicating test batch number and expiry
date; indicate operator name and date.
• Check that expiry time has not lapsed.
• After appropriate time, validate that test is working properly by
using positive and negative controls; you are now ready to start
testing clinical specimens.
• Write specimen number on worksheet.
• Remove test device from protective wrapping.
• Write specimen number on test device.
• Proceed to test-specific instructions.
This is an example of a testing plan based on Uni-Gold HIV™, Determine
HIV™1/2 and HIV 1/2 Stat-Pak™. Adapt to your country’s chosen kits.
❖ Uni-Gold HIV™
• Prepare test kit (see above).
• Collect whole blood finger prick using included disposable pipette.
• Add two drops of blood from the pipette to the sample port.
• Add two drops of wash reagent to the sample port.
• Allow ten minutes for reaction to occur.
• Read result immediately at the end of ten minutes. Do not read
after 20 minutes as result is no longer stable.
• Interpret result.
121
One line in the control region: Negative result
One line in the control region and
one in the test region: Positive result
No line in the control region
(with or without line in test region): Invalid result

• Record test result on worksheet. Interpretation of

• Post-test counselling.

❖ Determine HIV™ 1/2


• Prepare test kit (see p. 121).
• Collect whole blood finger prick using EDTA capillary tube.
• With the capillary tube apply 50 µl of sample to the sample pad
(marked by arrow symbol).
• Wait until blood is absorbed and then apply one drop of chase
buffer to the sample pad.
• Allow 15 minutes for reaction to occur.
• Read the result. Result should be read
between 15–60 minutes after sample addition.
• Interpret result.
Red bar in the control region: Negative result
Red bar in the control region and
red bar in the patient region: Positive result
No bar in the control region Interpretation of
(with or without bar in patient region): Invalid result

• Record test result on worksheet.


• Post-test counselling.

122
NEGATIVE
A line in the
control region
only indicates POSITIVE
a negative test A line of any
result. intensity in the
test region,
plus a line
test result forming
in the control
region, indicates
a positive result.

INCONCLUSIVE
No line appears in
the control region.
The test, should be
repeated with a fresh
device, irrespective of
a line developing in
the test region.

Negative Positive Invalid Invalid

Control
test result

Patient

123
❖ HIV 1/2 Stat-Pak™
• Prepare test kit (see p. 121).
• Collect whole blood finger prick using sample loop provided.
• Touch loop to center of sample well, holding loop vertically.
• Add 3 drops of buffer, holding vial vertically.
• Allow 10 minutes for reaction to occur.
• Read the result. Result should be read
between 15–60 minutes after sample addition.
• Interpret result.
One line in the control region: Negative result
One line in the control region and
one in the test region: Positive result
No line in the control region
(with or without line in test region): Invalid result

• Record test result on worksheet.


• Post-test counselling.

S T C S T C S T C

NEGATIVE POSITIVE INCONCLUSIVE


A line in the control region A line of any intensity in the No line appears in the control
only indicates a negative test region, plus a line region. The test should
test result. forming in the control region, be repeated with a fresh
indicates a positive result. device, irrespective of a line
developing in the test region.

❖ At the end of the working day, store materials as appropriate.


Clean the testing area with disinfectant.

124
Strategy for Use of Rapid HIV Tests
in Testing and Counselling Services*
Pre-test information and education

First HIV rapid test (screening test)

POSITIVE test result Negative test result


Counsel for negative
result and see p. 103-105.

Second HIV rapid test (confirmatory test)

Two positive test results


• Counsel for positive result Negative test result
and see p. 103-105. • Consider if recent
• Provide written confirmation of positive exposure possible.
test with date, name, facility. If so, repeat as
• Initiate care and treatment as appropriate. above in 14 days, or
• Refer.
See Chronic HIV Care module.

* Strategy is applicable for countries with HIV prevalence greater than 5%. For countries with HIV
prevalence less than 5%, adapt according to the IMAI Country Adaptation Guide.

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INTEGRATED MANAGEMENT OF ADOLESCENT/ADULT ILLNESS

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ACUTE CARE RECORDING FORM
Name:_______________________________ Sex:_____ Age:______ Weight:_____ BP:____ (if not measured
within year or if hypertension)
What are the patientʼs problems? _____________________________________________________
Acute illness / Follow-up acute / Follow-up chronic Quick check–emergency signs? Yes No If yes,_________________

ASSESS (circle all signs present) CLASSIFY


___Yes ___No DOES THE PATIENT HAVE COUGH OR DIFFICULT BREATHING?
If yes, ASK: LOOK, LISTEN:
�� For how long?____ �� Is the patient: Lethargic? Confused? Agitated?
�� Are you having chest pain? If yes, new? Severe? �� Count the breaths in one minute: ____ Fast Very fast
Describe it:_ Pleuritic breathing? breathing?
�� Night sweats? �� Look/listen for wheezing.
�� Do you smoke? �� Measure temperature _____ < 35°C 37.5°C or above >40°C
�� On treatment for: �� If not able to walk unaided or appears ill, also:
Asthma? - Count pulse:______ - Measure BP:________
Emphysema or chronic bronchitis (COPD)? �� Uncomfortable lying down?
Heart failure?

All patients
TB?
If no: Have you had previous episodes of cough
or difficult breathing? Recurrent episodes
If yes:
- Do these episodes wake you up at night or in
the early morning? Yes No
- Do they occur with exercise? Yes No

X CHECK ALL PATIENTS FOR UNDERNUTRITION AND ANAEMIA


�� Have you lost weight? �� Look for visible severe wasting:
�� Taking medications? Loose clothing? Did it fit before?

All patients
Which ones? ______________________ �� If wasted or weight loss:
�� If wasted or weight loss: Weight:_____kg Wt loss_____% MUAC______
- Diet: Problem:________________________ - Sunken eyes? - Oedema to knee? - Pitting?
- Alcohol use? �� Look at palms and conjunctiva for pallor. Severe pallor?
�� Pallor? If pallor: Black stools? Some pallor? If pallor,
- Blood in stools? - Blood in urine? - Count breaths in one minute:_____
�� If menstruating: Heavy periods? - Breathless? - Bleeding gums? - Petechiae?
- Measure haemoglobin:________
___Yes ___No DOES THE PATIENT HAVE ANOGENITAL ULCER OR SORE?

patients
�� Are these new? Recurrent? �� Look for anogenital sores. If present, are there vesicles?
- Blood in stools? - Blood in urine? - Count breaths in one minute:_____
�� If menstruating: Heavy periods? - Breathless? - Bleeding gums? - Petechiae?
- Measure haemoglobin:________
___Yes ___No DOES THE PATIENT HAVE ANOGENITAL ULCER OR SORE?
�� Are these new? Recurrent? �� Look for anogenital sores. If present, are there vesicles?
�� Look for warts.

All patients
�� Look/feel for enlarged lymph node in inguinal area.
If present, is it painful?

___Yes ___No DOES MALE PATIENT HAVE DISCHARGE FROM PENIS? ANY OTHER GENITO-
URINARY SX OR LOWER ABDOMINAL PAIN?
�� What is your problem?_________________________ Genital exam:
�� Discharge from urethra? �� Look for scrotal swelling · Feel for tenderness.
- If yes, for how long? �� Look for ulcer · Look for urethral discharge
�� Burning or pain when you urinate? �� Feel for rotated or elevated testis.
�� Pain in your scrotum? �� Feel for abdominal pain. If tenderness:

All patients
- If yes, have you had any trauma there? - Rebound? - Guarding? - Mass?
�� Do you have sores? - Absent bowel sounds? - Temperature:______
- Pulse:______

___Yes ___No DOES THE PATIENT HAVE MOUTH OR THROAT PROBLEM?


�� Do you have pain? If yes, Tooth, mouth or throat? Look in mouth for:
- When swallowing? - When hot or cold food? �� White patches
- If yes, can they be removed? Yes No
�� Problems swallowing? �� Ulcer
�� Problems chewing? - If yes, deep or extensive?
�� Not able to eat? - Tooth cavities - Loss of tooth substance
�� Taking medications? - Bleeding from gums - Swelling of gums
- Gum bubbles - Pus

All patients
Which ones? _____________________________
- Dark lumps
�� Look at throat for:
- White exudate - Abscess
- Swelling over jaw - Enlarged lymph nodes
�� If tooth pain, does tapping/moving tooth cause pain?

Prevention, prophylaxis—all patients Women of childbearing age: Adolescent girls:


�� Encourage insecticide-treated bednet �� Update tetanus toxoid �� Update tetanus toxoid
�� Counsel on safer sex • Offer HIV testing and counselling �� Give mebendazole if due �� Encourage delay
�� Offer family planning • Counsel to stop smoking �� If pregnant, give antenatal care interventions if
�� Counsel to reduce or quit alcohol �� If not pregnant, offer family planning sexually active

All patients
�� If back pain history or risk, teach exercise & correct lifting
�� Measure BP

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___IF FEVER (by history or feels hot or temperature 37.5ºC or above) CLASSIFY
�� How long have you had a fever? ________ �� Is the patient: Lethargic? Confused? Agitated?
�� Any other problem? Medications?_______________ �� Count the breaths in one minute:_______ Fast breathing?
�� Have you taken an antimalarial in the previous week? - If fast breaths, is it deep?
If yes, what and for how long? _________________ �� Check if able to drink Not able to drink
�� Feel for stiff neck
Decide malaria risk: High Low No
- Where do you usually live?
�� Check if able to walk unaided Not able to walk unaided
- Recent travel to a malaria area? �� Skin rash?
- If woman of childbearing age: Pregnant? �� Headache? If yes, for how long?_____ Prolonged
- Epidemic of malaria occurring? �� Look for apparent cause of fever_____________________
- HIV clinical stage 3 or 4?

____IF DIARRHOEA �� Look at the patientʼs general condition:


�� For how long? ______days - Lethargic? - Unconscious?
- If more than 14 days, have you been treated �� Look for sunken eyes.
before for persistent diarrhoea? Yes No �� Is the patient: - Not able to drink or drinking poorly?
- If yes, with what?_________ When?______ - Drinking eagerly, thirsty?
�� Is there blood in the stool? �� Pinch the skin of the inside forearm. Does it go back:
Very slowly (longer than 2 seconds)? Slowly?
___IF FEMALE PATIENT HAS GENITO-URINARY SX OR LOWER ABDOMINAL PAIN
�� What is the problem?______ Meds? ____________ �� Feel for abdominal tenderness. If pain:
�� Burning or pain on urination? - Rebound? - Guarding? - Mass?
�� Increased frequency of urination? - Absent bowel sounds?
�� Ulcer or sore in your genital area?
- Temperature______ - Pulse______
�� Abnormal vaginal discharge? If yes, does it itch?
�� Bleeding on sexual contact? �� External exam: - Large amount vaginal discharge?
�� Partner have problem? - Anal/genital ulcer? - Enlarged inguinal lymph node?
If present, Ask: Urethral discharge or sore? �� If able to do bimanual exam, cervical motion tenderness?
�� Missed a period? If yes, possibly pregnant? �� If burning or pain on urination, percuss back: Flank pain?
�� When was last period?
�� Periods: heavy or irregular periods? If yes, new?
- Days of bleeding:____ Number pads used:_____
�� Very painful menstrual cramps?
�� Using contraception? Which?_________
�� If no, interested? If interested, use FP guidelines.

____IF SKIN PROBLEM OR LUMP �� Where are the lesions?


�� Do you have a sore or skin problem or lump? �� How many are there?
- If yes, where is it? �� Are they infected (red, tender, warm, pus or crusts)?
- If yes, for how long? - Are they tender?
�� Is there itching? - Does it hurt? - Is there sensation to light touch?
- Duration________ - Discharge? �� Feel for fluctuance.
�� Do other family members have same problem?
____IF SKIN PROBLEM OR LUMP �� Where are the lesions?
�� Do you have a sore or skin problem or lump? �� How many are there?
- If yes, where is it? �� Are they infected (red, tender, warm, pus or crusts)?
- If yes, for how long? - Are they tender?
�� Is there itching? - Does it hurt? - Is there sensation to light touch?
- Duration________ - Discharge? �� Feel for fluctuance.
�� Do other family members have same problem? �� Look/feel for lumps.

____IF HEADACHE OR NEUROLOGICAL PROBLEM


�� Weakness in any part of body? �� Assess for focal neurological problems:
�� Recent accident or injury involving head? - Test strength - Look at face: flaccid on one side?
�� Convulsion? - Problem walking? - Problem talking?
�� Alcohol use?__________ Drug use?___________ - Flaccid arms or legs? If yes, loss of strength?
�� Medications?______________________________ �� Feel for stiff neck.
�� Brain/mind working more slowly? �� Measure BP:_____
�� Trouble keeping attention? �� Is patient confused?
�� Forget things that happened recently? �� If patient reports weakness, test strength.
�� Ask family: - Patientʼs behaviour changed? �� If headache, feel for sinus tenderness.
- Memory problem? �� If confused or disoriented:
- Patient confused? - Physical cause? - Alcohol or drug medication or toxicity?
- If confused, when did it start?______ - Withdrawal?
- Disoriented to place or time?
�� If memory problem, test registration/recall
�� If headache: �� Name 3 unrelated objects, clearly and slowly. Ask
patient to repeat them.
- For how long? - Visual defects? - Vomiting?
- One-sided? - Prior diagnosis of migraine? �� Can he/she repeat them? (registration problem?)

____IF MENTAL PROBLEM, LOOKS DEPRESSED OR ANXIOUS, SAD, FATIGUED, ALCOHOL PROBLEM
OR RECURRENT MULTIPLE PROBLEMS
�� How are you feeling? (listen without interrupting) �� Does patient appear: Agitated? Restless? Depressed?
�� Do you feel sad, depressed? �� Patient disoriented to time and place? Is patient confused?
�� Loss of interest/pleasure?
�� Does the patient express bizarre thoughts? If yes:
�� Loss of energy? If yes to any of the above 3
- Does the patient express incredible beliefs (delusions) or
questions, ask for depression symptoms:
sees or hears things others cannot (hallucinations)?
- Disturbed sleep - Appetite loss (or increase)
- Poor concentration - Moves slowly - Is the patient intoxicated with alcohol or on drugs which
- Decreased libido - Loss of self-confidence or esteem might cause these problems?
- Guilty feelings - Thoughts of suicide or death
�� Have you had bad news? �� Does patient have a tremor?
�� Do you drink alcohol? If yes: If suicidal thoughts, assess the risk:
- Drinks/week over last 3 months:____ - Do you have a plan? - Determine if patient has the means.
- Find out if there is a fixed timeframe.
- Have you been drunk more than 2 times in past - Is the family aware?
year? - Has there been an attempt? How? Potentially lethal?

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Acute Care Acronyms
AIDS Acquired Immunodeficiency Syndrome
ARV Antiretroviral
ART Antiretroviral Therapy
BP Blood Pressure
BV Bacterial Vaginosis
CD4 Count of the lymphocytes with a CD4 surface marker per cubic millimetre
of blood
cm Centimetre
COPD Chronic Obstructive Pulmonary Disease
EPI Expanded Programme on Immunization
GC Gonorrhoea
GI Gastrointestinal
GYN Gynaecological
Hg Mercury
HIV Human Immunodeficiency Virus
IM Intramuscular
IMAI Integrated Management of Adolescent and Adult Illness
IMCI Integrated Management of Childhood Illness
IMPAC Integrated Management of Pregnancy and Childbirth
INH Isoniazid
IU International Units
IUD Intrauterine Device
IV Intravenous
kg Kilogram
mcg Microgram
MD Medical Doctor
MDT Multi-Drug Therapy (for leprosy)
mg Milligram
ml Millilitre
mm Millimetre
MO Medical Officer
MUAC Middle Upper Arm Circumference
NG Naso-gastric
NPO Nothing per os = nothing by mouth
ORS Oral Rehydration Solution
PCN Penicillin
PGL Persistent Generalised Lymphadenopathy
PID Pelvic Inflammatory Disease
PMTCT Prevention of Mother to Child Transmission (of HIV)
RF Rheumatic Fever
RHD Rheumatic Heart Disease
RPR Rapid Plasma Reagent test for syphilis
RPM Rotations per Minute
STIs Sexually Transmitted Infection
Td Tetanus Diphtheria
TB Tuberculosis
TT Tetanus Toxoid
ZDV Zidovudine

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